leadership strategies to achieve organizational excellence
TRANSCRIPT
Walden University Walden University
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Walden Dissertations and Doctoral Studies Walden Dissertations and Doctoral Studies Collection
2020
Leadership Strategies to Achieve Organizational Excellence Leadership Strategies to Achieve Organizational Excellence
Cherron Lakisha Blakely Walden University
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Walden University
College of Management and Technology
This is to certify that the doctoral study by
Cherron L. Blakely
has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made.
Review Committee Dr. Jill Murray, Committee Chairperson, Doctor of Business Administration Faculty
Dr. Rocky Dwyer, Committee Member, Doctor of Business Administration Faculty
Dr. Lisa Cave, University Reviewer, Doctor of Business Administration Faculty
Chief Academic Officer and Provost Sue Subocz, Ph.D.
Walden University 2020
Abstract
Leadership Strategies to Achieve Organizational Excellence
By
Cherron L. Blakely
MBA, Saint Leo University, 2013
BA, Saint Augustine’s College, 2000
Doctoral Study Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Business Administration
Walden University
July 2020
Abstract
Inadequate quality management tools and processes can lead to inefficient hospital
operations and poor organizational performance. Community hospital leaders who fail to
improve operations and organizational performance risk negatively impacting patient
care and profitability. Grounded in the theory of high-performance work systems
(HPWS), the purpose of this qualitative single case study was to explore strategies
community healthcare leaders use to effectively employ quality management approaches
to improve operations and achieve organizational excellence. The participants comprised
5 community healthcare leaders in the northeast United States who effectively used
quality management approaches to improve operations and achieve organizational
excellence. Data were collected from semistructured interview questions and company
documents. Thematic analysis was used to identify 5 strategies: quality management tools
and techniques, data measurement and analysis for performance improvement, strategic
planning, leadership engagement, and sponsorship, employee engagement, and
deliberative management of resources. Key recommendations include pursuing business
process improvement, using high-performance work system strategies, investing in
special quality training, and enhancing in-house quality management staff. The
implications for social change include the potential for hospital leaders to reduce waste,
improve healthcare delivery, and operational efficiency, resulting in a healthier patient
population and community.
Leadership Strategies to Achieve Organizational Excellence
by
Cherron L. Blakely
MBA, Saint Leo University, 2013
BA, Saint Augustine’s College, 2000
Doctoral Study Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Business Administration
Walden University
July 2020
Dedication
I dedicate this study to the women in my life who were both critical in raising and
remind me that I could be anyone in this world; my mother, Carrie Rhodes Turner and
my late grandmother, Clorine Dunkley. I also dedicate this study to the men from my
childhood and beyond that were my constants until I met my husband; my uncle, William
Dunkley and my “Pops,” Albert Turner. You all set fine examples and fostered an
environment for me to flourish in life.
I also dedicate this study to my nuclear family who were all supportive during this
journey. You all do not realize how the thought of each of you and our life together has
motivated me to overcome my greatest challenges. Thank you to my husband, John
Blakely, our daughters, Brittany and Tiffany Blakely, for allowing me to pursue the keys
to unlock my doors to personal excellence!
"The will to win, the desire to succeed, the urge to reach your full potential...these
are the keys that will unlock the door to personal excellence." (Confucius)
Acknowledgments
I would like to acknowledge all of the individuals who were supportive and
helpful during my quest to complete this journey. I am grateful to co-workers,
academicians, family members, an extended network of professionals, and close friends
who all provided an ear, sounding board, encouragement, and prayers in support of my
success.
I would also like to thank my chair and mentor, Dr. Jill A. Murray, for seeing the
potential in my research, taking a chance, and coaching me through this process. Dr.
Rocky Dwyer, my second committee member, thank you for your positive and ever
encouraging words of motivation and optimism every step of the way. My URR, Dr. Lisa
Cave, for ensuring a quality scholarly product. Lastly, the “Dr. Murray Scholars” have
been my peer support network along this path and have all played a major role in my
doctoral pursuit. I would also like to thank the coordinator and healthcare executives
from the partner organization that participated in the study making it possible for me to
complete my data collection and share incredible findings with the world.
i
Table of Contents
List of Tables ....................................................................................................................... v
Section 1: Foundation of the Study ..................................................................................... 1
Background of the Problem ........................................................................................... 1
Problem Statement ......................................................................................................... 2
Purpose Statement ......................................................................................................... 2
Nature of the Study ........................................................................................................ 3
Research Question ......................................................................................................... 4
Interview Questions ................................................................................................. 4
Conceptual Framework ................................................................................................. 5
Operational Definitions ................................................................................................. 6
Assumptions, Limitations, and Delimitations ............................................................... 7
Assumptions ............................................................................................................ 7
Limitations ............................................................................................................... 7
Delimitations ........................................................................................................... 7
Significance of the Study ............................................................................................... 8
Contribution to Business Practice ........................................................................... 9
Implications for Social Change ............................................................................... 9
A Review of the Professional and Academic Literature ............................................. 10
Conceptual Framework ......................................................................................... 11
Alternate and Rival Theories ................................................................................. 16
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Quality Management Approaches ......................................................................... 19
Quality Management Tools ................................................................................... 26
Leadership Engagement in Quality ....................................................................... 33
Critical Areas of Focus for Organizational Performance Excellence .................... 35
QM Staff and Consultants ..................................................................................... 41
Evaluation Methods to Assess Organizational Performance Excellence .............. 42
Healthcare Studies of Improvement and Organizational Performance
Excellence .................................................................................................. 50
Transition ..................................................................................................................... 52
Section 2: The Project ....................................................................................................... 53
Purpose Statement ....................................................................................................... 53
Role of the Researcher ................................................................................................. 53
Participants .................................................................................................................. 55
Research Method and Design ...................................................................................... 57
Research Method ................................................................................................... 57
Research Design .................................................................................................... 58
Population and Sampling ............................................................................................. 61
Ethical Research .......................................................................................................... 63
Data Collection Instruments ........................................................................................ 64
Data Collection Technique .......................................................................................... 65
Data Organization Technique ...................................................................................... 67
iii
Data Analysis ............................................................................................................... 68
Reliability and Validity ............................................................................................... 70
Reliability .............................................................................................................. 70
Validity .................................................................................................................. 71
Transition and Summary ............................................................................................. 72
Section 3: Application to Professional Practice and Implications for Change .................. 73
Introduction ................................................................................................................. 73
Presentation of the Findings ........................................................................................ 74
Theme 1: Measurement and Analysis for Performance Improvement .................. 75
Theme 2: Strategy and Strategic Planning ............................................................ 81
Theme 3: Leadership Direction, Sponsorship, and Engagement .......................... 85
Theme 4: Employee Engagement and Empowerment .......................................... 90
Theme 5: Resource Management .......................................................................... 97
Other Contributing Strategies .............................................................................. 101
Applications to Professional Practice ........................................................................ 103
Implications for Social Change ................................................................................. 104
Recommendations for Action .................................................................................... 105
Recommendations for Further Research ................................................................... 106
The Role of the Quality Practitioner in an Organization ..................................... 107
Knowledge About Organizational Excellence Models and Frameworks ............ 108
Reflections ................................................................................................................. 111
iv
Conclusion ................................................................................................................. 111
References ....................................................................................................................... 113
Appendix A: Interview Protocol ..................................................................................... 141
Appendix B: Interview Questions ................................................................................... 144
v
List of Tables
Table 1. Reference to Measurement and Analysis for Performance Improvement ........... 76
Table 2. Reference to Strategy and Strategic Planning by Interview Participant .............. 82
Table 3. Reference to Leadership Direction, Sponsorship, and Engagement ................... 87
Table 4. Reference to Employee Engagement by Interview Participant ........................... 93
Table 5. Reference to Resource Management by Interview Participant ........................... 99
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Section 1: Foundation of the Study
U.S. healthcare continues to evolve to increase efficiency while improving
medical care delivery, reducing patient errors and waste (Adams, O'Brien, & Scruth,
2015). Leaders need strategies and the infrastructure to foster a work environment
committed to excellence through continuous improvement and high-performance
standards. According to Miller, Duesing, Lowery, and Sumner (2018), leaders have an
opportunity to leverage quality management practitioners in their operational strategy to
meet organizational challenges. To achieve excellence in hospitals, healthcare leaders
should cultivate an environment and a workforce that practices systems thinking, quality
vision with supportive organizational infrastructure, continuous improvement, and
adaptive capability (Vaughn et al., 2014). There are various quality management (QM)
methods, tools, and techniques that aid leaders, individuals, and teams to improve work
processes and achieve organizational excellence.
Background of the Problem
Some leaders achieve optimal organizational performance that results in excellent
patient care and patient satisfaction (Adams et al., 2015). Healthcare leaders need
strategies to employ QM tools and techniques effectively to consistently yield quality
healthcare delivery and overall exceptional organizational performance (Vaughn et al.,
2014). The findings of this study could contribute to academic and professional practice
by providing awareness of implementation strategies that healthcare leaders may use to
optimize the utilization of QM approaches to further optimize, improve performance in
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their organizations, and provide the highest quality patient care. Healthcare delivery
systems that provide high-quality patient care may help to maintain the overall health of
the surrounding community.
Problem Statement
Organizational leaders have implemented various quality management
philosophies and approaches, over the past 2 decades, in their quest to achieve
exceptional business outcomes and superior company performance (Kumar, Maiti, &
Gunasekaran, 2018). In a study conducted by Branco, Wicks, and Visich (2017), more
than 80% of community hospitals used some form of quality tool and process
improvement approach in healthcare. The general business problem that I addressed in
this study was that leaders lack a consistent use of quality management approaches to
improve performance in healthcare organizations. The specific business problem was that
some leaders in community hospitals lack the strategies to identify practices and
consistently employ quality management approaches effectively to improve processes
and achieve organizational performance excellence.
Purpose Statement
The purpose of this qualitative, single case study was to explore strategies that
community hospital leaders use to employ quality management approaches effectively to
improve operations and achieve organizational excellence. The target population was five
executive leaders within a community hospital in the northeast region of the United
States who have successfully leveraged quality management approaches to improve
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healthcare delivery and achieve organizational excellence. The findings from this study
may contribute to social change by improving healthcare delivery which can result in a
healthier patient population and community.
Nature of the Study
I used the qualitative methodology to conduct this study. Qualitative research is
viewed as interpretive because researchers explore the subjective meanings of the
behaviors and experiences under study (Saunders, Lewis, & Thornhill, 2019). Using a
qualitative research method requires observation in a natural setting to describe the
environment under exploration. Morgan (2015) defined quantitative research as forming
hypotheses, developing measures, collecting data, and building knowledge for examining
relationships among variables. I did not formulate or test hypotheses to build knowledge
about variables' relationships or groups' differences; therefore, the quantitative research
method was not suitable for this study. Mixed-methods research requires combining data
collection and analytical procedures using both quantitative and qualitative methods by
testing hypotheses and interviewing research participants (Turner, Cardinal, & Burton,
2017). I did not use the mixed-method design for this research study because I did not
plan to test hypotheses or variable relationships.
There are three types of qualitative research design that researchers can apply:
phenomenological, ethnographical, and case study. According to Yin (2017), a case study
design is useful for research explaining a circumstance or requiring an extensive
description of phenomena. Case study research is ideal when a group, organization, a
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change process, or an event is a key focus for understanding the nuances within a context
of the natural setting (Saunders et al., 2019). According to Aagaard (2017), the
phenomenological method is used to explore the meanings of participants' lived
experiences to produce a constructive understanding of the environment. Ethnographic
research is applied to describe the culture of groups through participant observation and
interviews with those under study (Oğuz, 2015). The goals for this study did not include
understanding the meanings of participants' experiencing phenomena or a description of a
group's culture through observation, which were my reasons for not choosing
phenomenology or ethnography designs.
Research Question
The primary research question in this study was: What strategies do leaders use in
community hospitals to effectively employ quality management resources to improve
operations and achieve organizational excellence?
Interview Questions
1. How does your organization define organizational performance excellence?
2. What quality management approaches do you use within your organization for
achieving operational efficiency and improvement?
3. How do you assess the effectiveness of your strategies to achieve the desired
performance outcomes?
4. How does your organization identify and prioritize the initial projects for
justifying and demonstrating the benefits of improving operations?
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5. What types of overall quality management or improvement training does your
organization provide to leaders, managers, and employees who participate in
improvement strategies?
6. What strategy is used to obtain employee involvement in improvement efforts?
7. How does your organization use cost or performance metrics to prioritize
improvements in your organization's key business processes?
8. What additional information would you like to share about your organization's
leadership strategies to effectively employ quality management approaches to
improve processes and achieve organizational performance excellence?
Conceptual Framework
The theory of high-performance work systems (HPWS) was the conceptual
framework I selected to shape this study. The Commission on the Skills of the American
Workforce introduced the HPWS theory (National Center on Education and the
Economy, 1990). HPWS is an integrated structure of practices that are internally and
externally consistent in an organization (Rasheed, Shahzad, Conroy, Nadeem, &
Siddique, 2017). The theory of HPWS was described by Boxall and Macky (2009) as the
method service industry firms use to shape operational focus to gain a competitive edge
and achieve organizational excellence. According to Jiang and Liu (2015), the common
elements in high-performing work systems are self-managed teams, decentralized
decision making, selective staffing, open communication, performance contingent-
compensation, and training. Boxall and Macky (2009) accounted for the use of HPWS
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theory across industries and discovered what works when empowered and enabled team
members to pool expert knowledge to make better business decisions. The HPWS
framework applied to this study because of major tenets of the theory aligned with the
characteristics of high-performing companies with exceptional performance and
organizational excellence.
Operational Definitions
Organizational performance excellence: The pursuit and achievement of
organizational goals to satisfy customers with superior results (Latilla, Frattini,
Petruzzelli, & Berner, 2018).
Process improvement: The action to enhance how one performs a set of job
functions or work tasks (Prasad, 2016).
Quality management: An approach using tools and techniques to aid in the overall
outcome in association with organizational functioning and improving services, products,
and business processes to generate positive customer satisfaction and competitive
advantage (Barouch & Ponsignon, 2016; Pimentel & Major, 2016).
Quality management tools and techniques (QMT&T): The critical factors that
should exist in an organization for successful use and application of QM approaches in
businesses (Bamford & Greatbanks, 2005).
Total Quality Management: A cross-functional approach using seven basic
quality tools focusing on customer satisfaction, process, product development, and
satisfying the customers' delight in the quality of products or services in use (Kumar et
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al., 2018).
Assumptions, Limitations, and Delimitations
Assumptions
Assumptions are expected in a study because researchers have no control over
factors that they cannot verify (Bansal & Corley, 2011). Assumptions are beliefs that the
researcher assumes are true (Ellis & Levy, 2009). For this study, I assumed that
participants would be open, honest, and truthful in their responses to interview questions.
Another assumption was that the organization that I researched would provide access to
documents related to the topic to provide data essential to supporting the study.
Limitations
Limitations of a study are explicit threats that are beyond the control of the
researcher but should be summarized (Prowse & Camfield, 2013). A limitation of this
study was that the sample size might not represent other organizations in the sector or
region. Another limitation was that the results of the study might not transfer or apply to
other industries or organizations. A third limitation was that participants would not be
able to acknowledge personal bias regarding successful or less desirable outcomes using
QM tools and techniques.
Delimitations
Delimitations are elements in a study that the researcher defines that are relative
to the place or manner they are constructed (Cunliffe, 2011). The purpose of this study
was to explore strategies leaders use to employ QM approaches to improve procedures in
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pursuit of organizational performance excellence in a single hospital. Personnel, other
than healthcare leaders, involved in the organizational performance were not be included
in the study. The interview questions exploring strategies for performance improvement
and organizational excellence did not address other administrative or operational areas in
healthcare management.
Significance of the Study
Healthcare delivery consists of elaborate and complex systems of tertiary centers
for significant medical needs and small community hospitals serving rural communities
that do not have easy access to specialty and sub-specialty care. As a result of healthcare
delivery complexity, organizational leaders should be able to determine the strategic
priorities that best serve the patients and communities they care for and equip the staff
with the competency to maintain efficient operations and provide satisfactory service.
Latham (2014) stated that leaders should use their influence to highlight the quality and
their training in improvement and transformation necessary to cultivate an environment
committed to providing the best service and continual improvement. Leaders of
healthcare delivery systems throughout the United States are hiring or contracting quality
consultants with the expertise and knowledge of lean principles, Six Sigma, facilitation,
process re-engineering, team building, project management, and other management
philosophies to drive optimal operations and improvement (Adams et al., 2015). Quality
departments help leaders plan and conduct initiatives to improve operational efficiency
and achieve exceptional performance throughout their organizations. Leaders within
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high-performing hospitals are most effective when they engage in improvement
initiatives, pursue organizational efficiency, and foster a culture committed to providing
quality healthcare for the benefit and satisfaction of their customers, the patients (Vaughn
et al., 2014).
Contribution to Business Practice
The results of this study might offer leaders strategies for achieving
organizational excellence and improvement through the development and deployment of
a variety of quality management methods, techniques, and tools. The rapid and ever-
changing evolution of healthcare requires a sustainable quality strategy that leaders can
leverage (Ramadan & Arafeh, 2016). Identifying strategies that assist leadership in
employing QM to improve overall performance, may increase patient satisfaction and
gain operational efficiency through the alignment of the organizational vision, mission,
values, goals, and objectives. According to Ramadan and Arafeh (2016), the delivery and
overall quality of healthcare have many dimensions to improve, including satisfaction,
timeliness, effectiveness, equity of care, efficiency, and patient-centeredness.
Implications for Social Change
The results of this study might provide leaders with an awareness of
implementation strategies to improve healthcare delivery from hospital executives who
have successfully created a culture of quality, high-performance, and continuous
improvement. When hospitals experience high efficiency and continued operational
improvement, funding becomes available for use in enhancing healthcare delivery. When
10
leaders leverage cost savings to target improvement throughout their hospitals, the funds
are typically used to acquire other resources for the staff (McFadden, Henagan, &
Gowen, 2009). Hospital improvements lead to better outcomes and improved quality of
patient care, which results in a healthier and happier patient populace (Adams et al.,
2015).
A Review of the Professional and Academic Literature
A researcher uses the literature review to demonstrate a depth of knowledge in a
field of study while exploring previous studies, ideas, theories, and findings in research
(Onwuegbuzie, 2018). The review of literature includes peer-reviewed articles, seminal
works, and informational textbooks. I used the research question to guide the exploration
of existing literature about the strategies that leaders use to maximize QM resource
utilization in their pursuit of organizational performance excellence. In this review of the
literature, I provide information about the conceptual framework that was used to shape
this study, prominent QM techniques and tools, critical success factors necessary for
achieving organizational performance excellence, leadership engagement in QM
activities, and the prevalent business models and evaluative methods to assess the degree
of organizational excellence maturity.
I reviewed the literature using Walden University Library databases to search for
peer-reviewed journals, seminal works, and informational books. The databases that I
used included ProQuest, Business Source Complete, ABI/INFORM Complete, Academic
Search Complete, ScienceDirect, Taylor & Francis, Emerald Management, and
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EBSCOhost. I organized the literature review into nine sections including the following
keywords to conduct forward, and backward searches of select databases: (a) conceptual
framework high-performance work systems, (b) alternate and rival theories, (c) quality
management tools and techniques, (d) leadership engagement in quality, (e) QM staff and
consultants, (f) organizational performance excellence, (g) evaluation methods to assess
organizational performance excellence, and (h) healthcare studies of improvement and
organizational performance excellence. I conducted additional searches of available
databases for the following keywords: business excellence models, business maturity
models, continuous improvement models, performance measurement, quality
management, total quality management, service quality, organizational change
management, and transformational leadership. The number of references included in this
study totals 187 sources. The breakdown of sources includes 165 (88%) articles
published between 2015–2020 and 25 (12%) articles from journals or textbooks
published before 2015.
Conceptual Framework
High-performance work systems. In this section, I discuss the HPWS
conceptual framework, the origin of the theory, the major tenets, supporting theories, and
studies that align with the use of this conceptual framework. The theory of HPWS
includes characteristics related to the findings in this study. Leaders use the tenets of
HPWS theory to improve organizational performance through employee commitment,
productivity, and capability (Posthuma, Campion, Masimova, & Campion, 2013). Evans
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and Davis (2015) defined HPWS as a system of highly-skilled and agile employees who
are empowered to affect change for improved performance of organizational work.
The origin of the conceptual framework that shapes this study began in the U.S.
federal government. The Commission on the Skills of the American Workforce (National
Center on Education and the Economy, 1990) first introduced the theory of high-
performance work systems to solve a 20-year problem occurring across the United States
of decreased productivity and stagnant wage earnings. High-performance work systems is
a strategic human resource management (SHRM) approach comprised of a system of
human resource practices that enhance productivity, employees' skills, and employees'
commitment for a company by breaking down job tasks into smaller repetitive
responsibilities (Fu, Flood, Bosak, Morris, & O'Regan, 2015). According to Wu, Hoque,
Bacon, and Llusar (2015), the HPWS elements include teamwork, employee
involvement, selective hiring, and extensive training that collectively create a positive
effect on organizational performance. The major elements of this conceptual framework
are the main reasons for selection and use of the theory in this study.
The major tenets of the theory of HPWS vary across the professional and
academic literature and in practice across industries. Organizations that implement
HPWS vary as leaders adopt elements key to their companies’ performance outcomes
(Shin & Konrad, 2017). According to Jiang and Liu (2015), the common elements in high
performing work systems are (a) self-managed teams, (b) decentralized decision making,
(c) selective staffing, (d) open communication, (e) performance contingent-
13
compensation, and (f) training. According to Posthuma et al. (2013), 61 independent
practices exist across nine core categories in HPWS that include (a) promotions, (b)
performance management, (c) turnover and retention management, (d) employee
relations, (e) communication, (f) recruitment and selection, (g) job and work design, (h)
training and development, and (i) compensation and benefits.
Caldwell and Floyd (2016) identified seven work practices prevalent in HPWS (a)
train by commitment, (b) high results-based compensation, (c) ensure employee security,
(d) reduce status barriers, (e) decentralize decision-making, (f) selective hiring, and (g)
share key information. Built as a system to increase employee commitment through
building trust by increasing decision-making, and creating partnerships, HPWS reduces
management control while expecting highly competent employees to pursue excellence
and improve the organization (Rasheed et al., 2017).
According to Arthur, Herdman, and Yang (2016), the following eight program
operational areas are the primary features of HPWS: (a) internal promotions, (b)
information sharing, (c) employment security, (d) performance-based pay, (e)
autonomous job design, (f) performance appraisals, (g) employee participation, and (h)
employee training and development. Without a universal definition of HPWS, different
variations of the doctrine exist across industries. The following recurring components of
the conceptual framework are in use across most industries: (a) skilled workforce, (b)
leader and employee engagement, and (c) information sharing and knowledge
management.
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Talented and high-quality workforce. According to Arnold, Goodson, and
Duarte (2015), developing the workforce is necessary to sustain a high-performing
workforce that is equipped to improve, deal with rapid changes, and function effectively
in a dynamic environment. To build a qualified and high-skilled workforce, leaders can
initiate work practices, including career development, extensive training, selective hiring
initiatives, and use a robust recruitment process (Robbins, Garman, Song, & McAlearney,
2012). Employees in high performing organizations receive ongoing training to sustain
competency in their area of expertise and QM specialty training to continuously improve
operations and processes (Etchegaray & Thomas, 2015). When leaders involve
employees in targeting changes to improve the work environment, employee engagement
increases.
Employee and leader engagement. Employee engagement has a positive impact
on productivity, performance outcomes, satisfaction, financial revenue, and
organizational excellence (Bakker, 2017). According to Stoyanova and Iliev (2017), the
characteristics of an engaged employee include their identification with the organization,
visualization of the bigger organizational picture with a positive outlook, and constant
search for opportunities to improve organizational performance. Organizational leaders
who focus on employee engagement ensure employees interact with managers, clients,
colleagues, and stakeholders in ongoing daily activities (Shantz, 2017).
Information sharing and knowledge management. Information sharing is
commonly known as knowledge management, which is the procedure in businesses for
15
saving, disseminating, and acquiring information that employees share in the
performance of work duties (Ashraf, 2016). According to Zawila-Niedźwiecki (2015),
high-performing organizations’ managerial knowledge and information through actions
of procurement, processes, storage, distributive activities ensure widespread reach to the
entire workforce. Healthcare workers provide high-quality service and satisfy customers
when employees harness their knowledge and expertise (Ashraf, 2016).
HPWS in healthcare. There are limited studies on the use of HPWS in the
healthcare sector within the United States. Robbins et al. (2012) found the following
subsystem of components in a study of HPWS theory utilization in a healthcare delivery
system: (a) a highly-skilled quality workforce, (b) high staff engagement and
commitment to work, (c) leader influence to run the organization, and (d) empowerment
of frontline staff. Healthcare executives highlighted information sharing, teamwork,
training, empowerment, performance appraisals, process improvement, and the use of
quality management techniques among the most important HPWS practices that have a
direct impact on patient safety (Etchegaray & Thomas, 2015). Kellner, Townsend, and
Wilkinson (2017) examined the HPWS framework in the health care system and found
the key tenets in use, such as performance management and teamwork, significantly
impacted employee behavior and organizational performance. Shin and Konrad (2017)
explored causality between organizational performance and the use of HPWS in
companies and discovered that organizations gradually implement HPWS as the
workforce matures in knowledge and experience.
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The application of the major HPWS tenets exists globally in non-healthcare
settings. According to Etchegaray and Thomas (2015), HPWS utilization is more
prevalent in other industries than healthcare. Elorza, Harris, Aritzeta, and Balluerka
(2016) discovered that employees and managers have differing views and perceptions of
the application of HPWS theory, the impact on individual behavior, organizational
outcomes, and performance. The use of HPWS is costly to implement although
organizations can gain benefits from the use of the tenets that will result in an
improvement in organizational performance, customer satisfaction, and overall employee
commitment (Hong, Jiang, Liao, & Sturman, 2017). Lee, Werner, and Kim (2016) found
substantial investment associated with an incomplete implementation of the HPWS
theory resulting in a decrease in employee attraction towards companies that lack focus
on quality. The use of the general systems and agency theories complement HPWS and
may also be in use within companies.
Alternate and Rival Theories
General systems theory. General systems theory (GST) is one of many subsets
of organizational theory introduced by Von Bertalanffy in 1968 as a means to improve
firm performance with an emphasis on external and internal feedback loops (Shin &
Konrad, 2017). The adaptive process of GST complements the use of HPWS as both
theories build iterative utilization and gradual integration of practices when the workforce
matures with knowledge, skill, and competency. The founders of GST believed the
approach supported team communication, cooperation, knowledge and information
17
sharing, and promotion of scientific discovery across disciplines (Rousseau, 2015). Caws
(2015) opined that to grasp a system, one should be able to engage in a point of view that
is outside of the system under study. Issues with GST includes ambiguity and varying
interpretation due to the complexity and lack of widespread use of GST in business
practice.
Confusion and theoretical debate about GST are the primary reasons that I did not
use this theory as the conceptual framework for this study. Although research about GST
utilization suggests that implementation of the theory promotes improvement when
managers discover feedback about business practices, the theory does not include drivers
of change based on operational efficiency or the impetus to achieve optimal
organizational performance (Rousseau, 2015). GST tenets do not include professional
growth and development of the workforce, holistic communication that cascades to all
employees, or increasing employee engagement and empowerment. Leaders should
embrace philosophies and leverage techniques that not only improve the process, but also
enhance workforce actions, reduce expenses, increase revenue, and provide high-quality
service with satisfaction.
Agency theory. In researching conceptual frameworks that could shape this
study, agency theory was among the prospective theories aligning to the research
question about how leaders pursue organizational excellence. The agency theory, known
as the theory of the firm, was introduced in 1776 by Adam Smith and expanded by
additional theorists such as Ross and Mitnick, Alchian and Demsetz, and Jensen and
18
Meckling in successive decades (Panda & Leepsa, 2017). In 1976, Jensen and Meckling
expanded agency theory in economics by describing attributes focusing on decision
making, performance incentives, workplace relationships, and vertical and horizontal
interactions among employees in the workplace (Lopes, 2016). According to Evans and
Tourish (2017), agency theory is useful when exploring how organizations ensure the
alignment of interests for improved company performance. Hong et al. (2017) opined that
the use of agency theory allows the owner of a company to survive in the competitive
market and sustain business performance. Conflicts of interest and self-gain in a
workplace have resulted in the erosion of ethical behavior, corporate misfortune, and
financial collapse when leaders use agency theory irresponsibly (Evans & Tourish, 2017).
Evans and Tourish (2017) explained growing concern about the separation of
ownership and management, employee dedication, loyalty, and self-interest as
compromising factors in companies. Leaders are responsible for cultivating a work
environment that rewards employees who exhibit behavior that aligns with the company
values, ethics, code of conduct, and expectations (Evans & Davis, 2015). The concerns
about the self-serving use of agency theory may lead to risky corporate social
responsibility with compromising performance; which are the primary reasons I did not
select this theory as the conceptual framework for this study.
Management school of theories. There are management methods that are
considered general schools of thought that inform how leaders manage organizations.
Dahlgaard-Park, Reyes, and Chen (2018) identified the following methods of
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management theory categories: (a) the empirical school, (b) the mathematical school, (c)
the decision theory school, (d) the human behavior school, (e) the empirical school, and
(f) the social system school. The tenets of these theories include distinctive elements of
approaches and frameworks that managers use to solve problems. These theories are
identified as the management theory jungle due to a phenomenon of chaos and confusion
created as leaders attempt to implement without a roadmap (Dahlgaard-Park, Reyes, &
Chen, 2018). Fredriksson and Isaksson (2018) found that leaders use Total Quality
Management (TQM) and a variety of quality management techniques to align business
processes with strategic goals.
Quality Management Approaches
There are QM tools and techniques that originated with the introduction of
common QM philosophies. There are several quality management philosophies and
approaches to improve business operations that leaders can leverage in any industry or
geographic location (Tickle, Adebanjo, Mann, & Ojadi, 2015). Fredriksson and Isaksson
(2018) found that within an organization, a QM philosophy exists with supportive and
foundational elements, principles, methods, and tools. There are several quality principles
attributed to pioneers such as Shewhart, Deming, Crosby, Juran, Ishikawa, Shigeo
Shingo, and Feigenbaum; who shared the common belief that everyone in an organization
should engage in continuous improvement (Dahlgaard-Park et al., 2018). According to
Kumar et al. (2018), leaders around the world adopt quality management philosophies
and appropriate tools to assist their organization in meeting strategic objectives, improve
20
business processes, and drive overall performance achievements. Dahlgaard-Park et al.
(2018) identified companies and quality experts around the world known for
implementing QM philosophies and models of excellence to include Toyota production
systems and Xerox. Fredriksson and Isaksson (2018) recommended three foundational
principles necessary for the successful use of QM tools and techniques to improve
business practices: teamwork, a culture of continuous improvement, and a focus on
satisfying customer needs.
A review of practitioners' utilization and outlook of the various quality
management techniques and tools revealed a lack of consistency and sustainability in
some organizations. The lack of consistency has impeded the widespread and consistent
application of the same appropriate approaches to solving organizational problems,
improving operations, and achieving excellent performance (Carnerud, 2018). According
to Ismyrlis (2017), the evolution of the existing quality philosophies to the total quality
management (TQM) framework caused an international expansion of the use of quality
approaches in organizational management systems. Within the QM community,
practitioners regard TQM as the foundational management philosophy and backbone for
the various QM philosophies in use (Dahlgaard-Park et al., 2018). Fredriksson and
Isaksson (2018) discovered that organizations use different QM philosophies when one
philosophy fails to assist leaders in delivering the expected organizational results. Tickle
et al. (2015) examined the common techniques adopted across business sectors and
highlighted various industries that place a different emphasis on quality management
21
adoption, utilization, and implementation. According to Fredriksson and Isaksson (2018),
organizations will augment their QM approach with defined tools to capture pertinent
operations data, skilled staff in data analysis, and decision-making mechanisms to drive
the key performance indicators organizational leaders identify as pertinent to success.
The key to the leadership strategy to pursue organizational excellence is the
selection of the best methods and tools to improve operations. According to Tickle et al.
(2015), choosing the appropriate tool is paramount to success, given the hundreds of
existing strategies in use in improvement projects. Ismyrlis (2017) discovered that large
organizations typically implement more than one QM method resulting in more skilled
and specialized quality staff to assist with the organizations' improvement initiatives.
Fredriksson and Isaksson (2018) discovered that leaders use parallel quality philosophies
concurrently for accomplishing organizational improvement. Across the various QM
philosophies, quality principles, and tools, practices are interchanged and used in
improvement projects.
Zeng, Zhang, Matsui, and Zhao (2017) found that during the last 20 years, QM
adoption has been widespread and associated with a company's financial and operational
performance goals and results. Leaders should focus on QM implementation strategies
before conducting training and chartering improvement teams. Dubey (2016) found
higher failure rates of QM implementation in companies that fail to take a
comprehensive, holistic approach to the widespread and cascading utilization of quality
methods and tools. Hospital leaders included in a research study were found to use at
22
least one problem identification and solving tool with various quality methodologies
(Branco et al., 2017). Firms that neglect staff competency and training in quality and
improvement methods, but promote employee participation, overlook the systematic
encouragement necessary for ensuring success in projects and continuous monitoring of
sustainment and control plans (Zeng et al., 2017). Fredriksson and Isaksson (2018) stated
the importance of combining organizational principles with the appropriate quality
concept and tools in use. The effective use of QM techniques and tools to achieve
organizational performance excellence can be unsuccessful if leaders and staff do not
learn the purpose and appropriate use of various approaches (Bamford & Greatbanks,
2005).
QM Philosophies
Organizations often adopt a QM method while avoiding the full implementation
of a specific QM philosophy. In contrast, leaders of organizations will also implement
more than one philosophy. Kumar et al. (2018) identified the following common quality
philosophies and management methods that are known and widely accepted for the past
twenty years: (a) TQM, (b) Six Sigma, (c) Lean manufacturing, (d) theory of constraints,
and (e) the International Organization for Standardization (ISO) 9001 standards. Of these
methods, TQM is considered the most evolved and used to boost organizational
management and performance (Ismyrlis, 2017). The latter systems lean, the theory of
constraints, and ISO 9001 are in use less frequently (Jacobs, Swink, & Linderman, 2015).
Total quality management. Total quality management is the most common
23
global QM philosophy across industries. Many quality practitioners consider TQM
philosophy and techniques as the overarching method in use within an organization
(Fredriksson & Isaksson, 2018). Breja, Banwet, and Iyer (2016) defined TQM as a set of
activities carried out across a company efficiently and effectively to achieve goals while
providing the highest quality product or service to customers at the appropriate price and
time. Other researchers define TQM as a quality strategy to manage and implement
quality improvement efforts across an organization (Dahlgaard-Park et al., 2018;
Montgomery & Borror, 2017). Leaders use TQM to focus on customer delighters,
customer-focused improvements, and process enhancements to satisfy customers using
statistical tracking and monitoring methods (Kumar et al., 2018). Calabrese and Corbò
(2015) warned that five barriers impede successful adoption and implementation of TQM
principles: (a) lack of quality planning, (b) lack of leadership of quality efforts, (c)
inadequate resources, (d) lack of focus on customers, and (e) scarcity of TQM resources.
Aquilani, Silvestri, Ruggieri, and Gatti (2017) highlighted critical success factors
that are key to TQM implementation: top management commitment, leadership focus on
satisfaction, information and analysis, metrics, training and education, strategic planning
with QM department involvement, supply chain management, teamwork, service design,
process management, and employee relations and engagement. According to Eriksson
(2016), as companies fail in TQM implementation, they turned to other methodologies
such as Six Sigma and Lean. In contrast, Calabrese and Corbò (2015) outlined the
following stages of the quality management maturity via a grid for organizations to
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determine their stage of development or maturity: (a) stage 1-uncertainty, (b) stage 2-
awakening, (c) stage 3-enlightenment, (d) stage 4-wisdom, and (f) stage 5-certainty.
Fredriksson and Isaksson (2018) suggested that TQM functions are in use through three
interdependent components: tools, methods, and values.
Six Sigma. Six Sigma implementation is considered an administrative innovation,
which can vary by tools, and adoption strategy within organizations (Jacobs et al., 2015).
Almorsy and Khalifa (2016) found that many healthcare systems adopt quality
improvement approaches traditionally found in manufacturing such as Six Sigma; which
is a method that relies on a team effort to improve performance, remove waste, improve
speed and quality while improving customer satisfaction. Researchers defined Six Sigma
as a business improvement method that maximizes value by improving customer
satisfaction while improving the speed and quality of products or services provided while
cutting costs (Laureani & Antony, 2017). Some organizations currently combine the Lean
methodology with Six Sigma implementation as a combined QM strategy to improve
operational efficiency.
Lean manufacturing. According to Fredriksson and Isaksson (2018), Lean
thinking was a strategy Toyota implemented based on operational aspects such as people,
partners, interdependencies, and process management philosophy. Lean manufacturing is
a process improvement method aimed at delivering services and products faster and at a
lower expense. Branco et al. (2017) suggested that hospital leaders are adopting Lean
methodology, at an increasing rate, in tandem with other quality methods or tools to reach
25
their goals of improving healthcare delivery. Lean is considered an improvement method
that will enhance the quality of health care through the use of tools and data (Almorsy &
Khalifa, 2016). The nine steps in Lean implementation include finding a change agent,
knowledge, crisis, value stream mapping, reorganizing while removing non-value,
creating a Lean future state, sustaining improvements, policy utilization for
standardization and accountability, and customer engagement (Fredriksson & Isaksson,
2018). Tools commonly found in Lean methodology implementation include 5S, value
stream mapping, process mapping, and direct observation (Branco et al., 2017).
According to Rees and Gauld (2017), the use of lean in healthcare leverages HPWS
techniques such as teamwork, employee engagement, and a highly-skilled workforce for
continuous improvement efforts.
Theory of constraints. The theory of constraints (TOC) is considered a
management philosophy that recognizes limits of optimal performance in a system and
provides a set of measures or management systems to track (Gupta, Bridgman, & Kaur
Sahi, 2015). According to Kuruvilla (2017), the theory of constraints was developed by
Eliyaju Goldraft as a scheduling method in the manufacturing industry that recognized an
organizations' business units as many links in a chain connected by the working
relationships and mission. In healthcare, the TOC technique is becoming useful in
hospital measurement to identify scarce or critical services to improve efficiency and
measure the impact on the system of delivery. It is common practice to find the theory of
constraints utilization in tandem with Lean methodology in organizations
26
(D’Andreamatteo, Ianni, Lega, & Sargiacomo, 2015).
ISO 9001. Finally, ISO 9001 is the most recent QM philosophy that is a holistic
approach to managing a system of operations. According to Breja et al. (2016), ISO 9001
is a universal quality management system model that comprises four prongs:
management commitment, improvement, product or service realization, and resource
management aimed at meeting customer requirements. Quality professionals purport the
ISO standards to be a highly-acclaimed, effective tool in support of QM and an
international standard across multiple industries (Salgado, Beijo, Sampaio, Mello, &
Saraiva, 2016). Samman and Quenniche (2016) defined ISO standards as the template
documentation system that informs the essential elements of organizational procedures.
Quality Management Tools
Knowing the appropriate tool or technique to solve business problems may have a
significant impact on the sustainability, credibility, and continued use of quality
management resources (Zeng et al., 2017). According to Ismyrlis (2017), the use of
various tools and techniques, in public and the private sector across manufacturing and
services industries, has resulted in the discovery of 21 common quality management tools
and techniques in existence. The following tools are most commonly used for process
management, benchmarking, and process improvement: (a) Six Sigma; (b) plan-do-
check-act cycles; (c) customer surveys; (d) balanced scorecard; (e) strengths, weaknesses,
opportunities, threats analysis; (f) business process re-engineering; (g) 5S; (h) quality
management system; (i) best practices; (j) focus on customer service and customer
27
satisfaction; (k) employee suggestion schemes; (l) process and value stream mapping;
and (n) questionnaires (Tickle et al., 2015).
Six Sigma as a tool. Companies implement Six Sigma as a quality management
philosophy and as an available tool to streamline procedures, reduce variation, and
remove waste. The model of Six Sigma includes the functions: define, measure, analyze,
improve, control (DMAIC). Six Sigma serves as a resource for strategic process
improvement using statistical data analysis to make reductions in defects that dissatisfy
customers (Almorsy & Khalifa, 2016). According to Branco et al. (2017), value stream
mapping is a QM tool widely used in Six Sigma to find value and non-value-added steps
and waste in procedures. Organizations that adopt Six Sigma as a tool have to cultivate a
hierarchical infrastructure and complete specialized training before using the tools to
target improving procedures and performance metrics (Jacobs et al., 2015).
Plan-do-check-act cycles. One of the QM pioneers, Shewhart, was the first to
introduce the four-step method: plan, design, check and act (PDCA) to improve a process
area (Samman & Quenniche, 2016). Montgomery and Borror (2017) opined that the
Shewhart or PDCA cycles are a fundamental process improvement tool that continues to
evolve, and organizations that use the Six Sigma DMAIC model leverage this tool. The
Shewhart cycle consists of a set of steps divided into four stages: plan, do, check and act;
the cycle continues as a team of employees test improvements in working conditions and
process changes until successful results are achieved to sustain and permanently
implement (Borkovskaya, Degaev, & Burkova, 2018). Improvement teams often pilot
28
procedural enhancements in procedures using the plan-do-check-act (PDCA) cycles
before sustaining permanent changes.
Customer surveys. The study of customer satisfaction is a common practice
across industries and global business to understand consumer behavior, to gauge the
satisfaction of service, and improve service or products (Liberati & Mariani, 2018).
Fredriksson and Isaksson (2018) stated that the aim of TQM implementation, in addition
to resource reduction, is to improve or maintain customer satisfaction. Customer surveys
are standard questions asking key stakeholders about basic needs, experiences, and
satisfaction with service or products (Willand, 2015). Many organizations query both
internal and external customers of service and product delivery to gauge experience
across the entire cycle of service. Most organizations design and operate their customer
satisfaction survey mechanisms through a controlled process with the quality
management department who then share scores internally and publicly for transparency
(Lee & Park, 2015). Customer satisfaction scores are one of many performance indicators
that organizational leaders track through a scorecard, dashboard, or report to determine
the efficiency of operations.
Balanced scorecard. Singh and Sethi (2017) defined the balanced scorecard as a
powerful tool that managers use to measure and track the performance of strategic
business outcomes across the organization in financial and non-financial areas.
According to Breja et al. (2016), companies that use the balanced scorecard to
significantly improve their processes, customer focus, and internal procedures by
29
maintaining metrics of business outcomes and translating strategy into action. The use of
the balanced scorecard provides organizational leaders with a snapshot of the
performance of their business for determining the need for improvement, additional
resources, or an early indication of issues in a department. The balanced scorecard allows
the organization to link short-term performance outcomes to long-term strategic goals
through the creation of working plans that track metrics (Singh & Sethi, 2017).
Strengths, weaknesses, opportunities, and threat analysis. Strengths,
weaknesses, opportunities, and threats (SWOT) analysis is a planning, development, and
decision-making tool to a program or service within an organization to identify areas of
focus for sustainment, improvement, and identification of strategic objectives to stay
competitive (Willis & Thurston, 2015). The SWOT analysis process includes facilitation
of team participants through a process to identify the strengths weaknesses, opportunities,
and threats in a program area before planning projects to mitigate weaknesses and
opportunities. According to Casselman, Onopa, and Khansa (2017), SWOT analysis is
useful in prioritizing initiatives, adjusting strategic positions in the competitive market,
and creating strategies to improve the product or service. Leaders should use SWOT
analysis when planning short-term objectives to achieve long-term strategic goals.
Business process reengineering. Business process reengineering (BPR) is a QM
tool mainly in use in the manufacturing industry. BPR is a large-scale method of analysis
tool that examines the relationships between processes, activities, time, cost, and the
resources to improve and optimize task completion across an integrated system (Hakim,
30
Gheitasi, & Soltani, 2016). According to Taher and Krotov (2016), business process
automation and reengineering are improvement methods to rethink and redesign
organizational processes to reduce cost, optimizing time to complete work, and improve
quality. Hakim et al. (2016) described a team’s completion of BPR through the following
steps: identify and categorize the business process; define business goals in implementing
BPR and associated metrics; evaluate the effect of each category of business process
through the use of quality function deployment.
5S. Kleszcz (2017) defined 5S as a tool for sorting and organization. Companies
use the 5S tool to eliminate waste and improve the use of resources through the following
five steps: sort, sort, set in order, shine, and sustain. 5S is used in healthcare to reduce
inventory, organize presurgical procedures, decrease travel, and other non-value-added
steps employees perform in their jobs (Randhawa & Ahuja, 2018). Companies often
implement 5S and other lean tools simultaneously as they seek to increase efficiency,
improve employee morale, reduce waste, and delay (Cardoso, Bassi, Bertosse, Saes, &
Achcar, 2018). The manufacturing sector uses 5S to ensure orderly operations in the
development of products. According to Randhawa and Ahuja (2018), the use of the 5S
methodology can improve process performance, standardization, and decrease operating
costs as a result of neat, clean, and efficient work areas.
Quality management system. According to Fredriksson and Isaksson (2018), the
quality management system (QMS) includes organizational values, purpose,
methodologies, and tools that leaders use in the organization. Silombela, Mutingi, and
31
Chakraborty (2018) described the QMS as an organization's infrastructure of hard and
soft QM tools and techniques to support programs and processes. Companies implement
a QMS as part of their business strategy while pursuing performance excellence and
process improvement (Solomon, Bester, & Moll, 2017). According to Ismyrlis (2017),
many organizations utilize the ISO 9001:2015 standards to establish a QMS due to the
design and purpose to organize the essential business procedures for success.
Best practices. Leaders use best practices in various systems, procedures, and
industries as an indication of a positive, successful practice with sustained effectiveness
and results (Goode, 2018). Best practices may be methods, process steps, or
administrative steps that industry leaders identify with consistently successful outcomes
with recommendations to replicate in other work areas (Ray et al., 2018). Phan et al.
(2018) defined best practices as the optimal functioning of a process that determines
successful spread and sustainment of procedures or steps by the workforce.
Customer service and satisfaction. Brcic and Latham (2016) stated that
customer satisfaction drives the level and service or product delivery to consumers across
business industries. Most businesses measure the level of quality of service customers
experience as a measure of organizational performance and success (Fernandes &
Solimun, 2018). Companies use customer surveys to measure and benchmark several
factors of service for customer feedback about their experience while obtaining products
or services from employees (Afthanorhan, Awang, Rashid, Foziah, & Ghazali, 2019).
Employee suggestion schemes. Employee suggestion systems are one of the
32
oldest forms of employee engagement tools that are in use for innovation and creativity
from employee ideas (Lasrado, Arif, & Rizvi, 2015). According to Lasrado, Gomiseck,
and Uzbeck (2017), employee suggestion schemes have proven to improve product
quality, improve the process, and the work environment. Employee engagement in
organizational improvement through the process of sharing ideas exists in most industries
and businesses. Employee suggestions will remain a common tool for employee
innovation because suggestion schemes allow work teams and individual participation in
organizational improvement through the generation of their ideas (Lasrado, 2015).
Process and value stream mapping. Carmignani (2017) considers value stream
mapping (VSM) as one of the best tools to eliminate non-value added steps while
completely mapping a process. VSM is a methodology included in the Toyota production
system improvement method and is considered the most effective mapping of a process
to include activities employees perform to create a product or provide service to a
customer (Sunk, Kuhlang, Edtmayr, & Sihn, 2016). Nowak, Pfaff, and Karbach (2017)
described the act of value stream mapping to quantify resources, visualize workflow and
restructure and reduce waste over five phases: current state process map development,
identification of waste, development of solutions, envision the future state, pilot new
process before implementation, measure outcomes post-implementation for success.
Questionnaires. According to Schrepp, Cota, Gonçalves, Hinderks, and
Thomaschewski (2017), questionnaires are the best method to obtain subjective data from
various stakeholders to gain the user experience of a product or service an organization
33
provides. Administrators create questionnaires that include classification and attitudinal
questions using a Likert-grading scale that may be given to customers via hard copy or
using automation such as a web service or telephone encounter (Hassine & Amyot,
2016). Zhang, Kuchinke, Woud, Velten, and Margraf (2017) found that companies
administer questionnaires by four data collection methods that yield different responses
to include a telephonic interview, online, offline, and a face-to-face interview. Well
written, simple, structured questions help companies collect responses that assist in
improving products and services (Hassine & Amyot, 2016).
Leadership Engagement in Quality
Leadership visibility and active participation in continuous improvement activities
are critical success factors essential to inspire the workforce to pursue organizational
excellence and foster a culture of quality and continuous improvement in any
organization (Laureani & Antony, 2017). Historically, the journey to implement a quality
program began with a leader, with organizational influence, attending a quality seminar
or reading a book who returns to their office charging managers to implement a new
method to become the best in business (Miller et al., 2018). Leaders at all levels should
engage in improvement activities to demonstrate the significance of their commitment to
excellence and building a great company. Liao, Chen, Hu, Chung, and Liu (2017) opined
that organizations should have supportive leadership, training in quality methods and
principles, the ability to articulate a vision and inspire innovation to achieve superior
performance. Calabrese and Corbò (2015) stated that a lack of leadership and
34
management support of quality impacts strategic planning, leadership development, the
maturity of a quality management system, the scarcity of QM resources, loss of focus on
processes, and a lack of employee involvement in improvement. Leadership involvement
in continuous improvement is vital for the successful implementation and sustainment of
QM philosophies, tools, and techniques that support exemplary performance (Laureani &
Antony, 2017).
Quality management training. Quality management is traditionally introduced
in an organization through communication, training, and the launch of improvement
projects (Miller et al., 2018). Everyone involved in QM program implementation should
train in areas such as team building, QM awareness, problem-solving skills,
communication, quality control, and technical aspects of their job, program, or process
area (Ngambi & Nkemkiafu, 2015). Laureani and Antony (2017) discovered five themes,
from their study of leadership for Lean Six Sigma, essential for effective use of QM
methods: communication, employee motivation, program deployment, leadership style,
and training. Tickle et al. (2015) opined that poor training, lack of leadership
involvement, and focus on skill in the use of improvement tools and techniques would
result in project failures. Leaders and employees alike should be trained in the business
excellence model of choice, to understand the practices of high-performance operations,
performance improvement, and continuous improvement through innovation that is
necessary to achieve organizational excellence (Arnold et al., 2015).
Project sponsorship. Leaders should support efforts to improve programs and
35
processes by launching team initiatives with clear goals and objectives. Ngambi and
Nkemkiafu (2015) stated that leadership involvement in improvement projects boosts
reduction in costs and employee satisfaction while also citing the emphasis of leadership
commitment to quality as critical to organizational performance. According to Laureani
and Antony (2017), leaders should target areas of resistance and get involved when
problems arise to assist teams in overcoming barriers to improvement. Leadership
sponsorship, commitment to improvement, and a keen focus on customer and stakeholder
requirements provide direction and focus on legitimate quality projects, which are the
actions taken when pursuing excellent business practices.
Focus on customers and stakeholders. According to Elkington, Pearse, Moss,
Van der Steege, and Martin (2017), leaders should develop skills in conflict management
and resolution to connect with the workforce, stakeholders, and build the necessary
customer orientation for business sustainability. Stakeholders and customers are
individuals who have an interest or stake in an organization's operation as a supplier, an
input, or output of a company's service (Appelbaum, Calcagno, Magarelli, & Saliba,
2016). Aquilani et al. (2017) stated that when companies involve customers and
stakeholders in process and service development, they co-create value, which
significantly impacts satisfaction.
Critical Areas of Focus for Organizational Performance Excellence
Companies describe organizational excellence as achieving the highest quality
outcomes of the services and products they provide to their customers based on
36
satisfaction and sales data. According to Carnerud (2018), fostering a culture of quality
has increasing importance in organizations that are pursuing quality and business
excellence. The organizational performance involves the leaders' and staff pursuing and
successfully achieving company goals and objectives to satisfy customers' needs with
superior results (Latilla et al., 2018). Ferdowsian (2016) opined the development and
operationalization of excellence and ethics in a company is essential for implementing
one of the emerging business excellence models and ultimately achieving the status of
excellence.
The most prominent internationally known business excellence models include
the Deming prize, Malcolm Baldrige national quality award, and the European
Foundation for quality management award (Garza-Reyes, Visnevskis, Kumar, & Antony,
2015). Organizational leaders who believe their companies demonstrate superior business
excellence often apply for assessment and awards from one of the business excellence
models as an indicator of achieving outstanding performance status. According to
Harrington (2005), businesses should focus and manage five pillars simultaneously to
achieve and sustain organization excellence: process management, knowledge
management, change management, resource management, and project management.
Leaders carefully combine the most appropriate quality management approaches and
business excellence practices that will collectively assist them in achieving organizational
performance excellence (Adams et al., 2015).
Process management. Managers perform process management at the micro- or
37
macro- levels and include factors such as inputs, outputs, suppliers, process steps,
customers, and process measurement (Harrington, 2005). Process management work is
completed by staff familiar with the work and commonly facilitated by quality
management personnel who are trained with various mapping techniques to include basic
flowchart, value-stream mapping, and swim lanes. According to Jacobs et al. (2015), to
achieve excellence, managers should continuously search for innovation, improve
business processes, and enhance operating performance.
Knowledge management. Organizations that successfully attain organizational
excellence establish environments where knowledge sharing exists, people learn, and
make contributions equal to initiatives (Ferdowsian, 2016). According to Harrington
(2005), the control of tacit and explicit knowledge of a business is essential for a
company's continuity, succession, and historical context of operational information.
Adams et al. (2015), stated that managers and quality consultants should possess
knowledge of performance improvement and strategic management to convey,
understand, and practice change and infrastructure development. Knowledge
management was emphasized by Ferdowsian (2016) as individualized energy each
employee in high-performing organizations should possess along with motivation,
commitment, personal satisfaction, ethical reasoning, responsibility, and creativity.
Change management. Leaders should manage change to lead organizations
through improvement successfully. According to Dubey (2016), flexibility is one of the
six stages necessary to evolve into an agile business excellence model company that can
38
perceive, react, anticipate, and recover from change. Jacobs et al. (2015) stated that
underperforming organizations are more likely to accept change in policy and practice
due to the need to challenge existing norms in pursuit of improvement. Rieley (2016)
believed organizational leaders should address those resistant to change to avoid a
shortage of change agents to make better decisions for the future. According to Adams et
al. (2015), the healthcare environment is high stress with constant variability; therefore,
an environment of resilience, creative solutions to problems, and the lack of change
inhibition should exist.
Resource management. High performing firms spawn innovation enabling
experimentation that leads to idea generation, especially when there are extra or excess
resources to practice improvement (Jacobs et al., 2015). Ferdowsian (2016) cautioned
leaders that to achieve excellence, they should maximize the use of resources by
addressing conflict, infighting, intense internal conflict among teams, or lack of cohesion
and alignment. In healthcare, the Dyad leadership model highlights human resource
management as a leadership domain with shared responsibility and critical for successful
outcomes in the improvement of care delivery (Saxena, Davies, & Philippon, 2018).
Project management. Projects are critical activities that enable staff in
companies to deliver quality service and products to customers (Harrington, 2005).
Successful project management includes teams tracking activity logs, key personnel, the
project charter, goals, and milestones over time (Bunger et al., 2017). According to
Harrington (2005), leaders should facilitate projects through process improvement and
39
change management to manage chaos organizations experience during implementation
phases.
According to Dubey (2016), organizations around the globe adopt QM models to
achieve system-wide organizational excellence. Leaders of organizations believe that if
they pursue an organizational excellence award, the act of preparing their employees and
organizing systems will result in operational efficiency (Jacobs et al., 2015). Leaders
should determine the critical success factors that are necessary to foster a culture of
excellence and sustained organizational performance (Ferdowsian, 2016).
Customer focus. The majority of quality management philosophies include a
component with emphasis on customer focus and satisfaction. There are many barriers to
successful program improvement; however, inadequate focus on customer needs is a
common challenge (Calabrese & Corbò, 2015). According to Carnerud (2018), within the
last ten years, program metrics considered essential in developing a quality culture that
has increased focus on customer requirements. Focus on customer needs and their
ongoing satisfaction is often included in continuous data collection as an indicator of
improvement and success in business outcomes.
Benchmarking. According to Tickle et al. (2015), monitoring, best practices, and
performance benchmarking are commonly used QM techniques to gauge organizational
success when compared to other companies, and industries around the world.
Measurement of program metrics and other quality data points comprise most evaluation
methods of organizational performance excellence (Chakraborty & Kaynak 2018).
40
Thurer, Tomasevic, Stevenson, Fredendall, and Protzman (2018) stated that excellence
models provide the framework for companies to compare themselves across the differing
and similar industries by benchmarking and performance scores.
Employee engagement. For employees to actively engage in quality management
activities, they should receive the training necessary for continuous improvement.
According to Calabrese and Corbò (2015), employees should understand how to improve
business performance, the purpose of their tasks, and be empowered to increase
involvement in the work environment. In a study exploring Six Sigma adoption, Jacobs et
al. (2015) explained that the chief executive officers who participate in the initial training
lead the effort and determine the focus of improvement projects to pilot before
implementing permanent changes. Jacobs et al. (2015) found that leadership's
engagement in the QM activities positively impacted the perception and early adoption of
organizational commitment to engage in Six Sigma learning and subsequent pilot projects
for improvement. Leadership and employee involvement are essential. An individual
competency to select the appropriate tools and techniques to utilize may be necessary to
improve a process or procedure successfully.
Effective quality function deployment. According to Ezzell, Cudney, Phelps,
and Mazur (2016), quality function deployment (QFD) is a structured, cost-effective,
timely, strategic planning tool to evaluate the best options to meet customer needs.
Quality function deployment is a methodology or tool for widely-used quality
management philosophy (Fredriksson & Isaksson, 2018). QFD involves the development
41
of a matrix after completing multiple steps to identify expectations. Often termed the
"house of quality," a quality function deployment matrix includes the voice of the
customer, customer requirements, and overall common organizational focus on
integrating customer demands (Dehe & Bamford, 2017). The use of QFD in
organizations results in a better understanding of needs, lower customer dissatisfaction,
improved quality of service, fewer problems and increased customer satisfaction (Ezzell
et al., 2016). Organizations develop QFD matrices to determine areas of focus and
purposeful identification of delight to satisfy customers. The QFD matrices can assist
analysts to capture vast amounts of customer requirement data with a competitor's
information to assist decision-makers (Dehe & Bamford, 2017).
QM Staff and Consultants
According to Fundin, Bergquist, Eriksson, and Gremyr (2018), QM practitioners
within organizations should work with leaders to advance the quality agenda and foster a
culture of continuous improvement in pursuit of organizational excellence. Ramu (2018)
urged organizational leaders and QM consultants to emphasize the importance of quality
based on the following primary responsibilities: (a) gather customer expectations, (b)
verify internal controls and compliance, (c) liaise with accrediting bodies, assessors, and
external reviewers, (d) manage customer complaints, (e) manage the document control
systems, and (f) performance measurement and monitoring. Yankelevitch (2015)
suggested that QM staff work with departments across an organization to achieve high
performance by breaking down barriers, using worthwhile QM approaches and tools to
42
assist with improvement. Quality management staff should constantly work to change the
misperception of a transactional paper maintenance unit through partnerships, adding
value by improving operational efficiency, and working with staff to prevent issues
(Ramu, 2018). Leaders and quality consultants commonly use business models, such as
Baldrige, to assess, reorganize, restructure, and streamline operations to improve
outcomes in healthcare (Parast & Golmohammadi, 2019). Griffith and Patel (2017)
discovered that organizations with supportive infrastructure, open culture for change
transformation, and consultants knowledgeable about organizational excellence models
are more successful in achieving superior performance outcomes. The role of the QM
consults can be pivotal in an organization on a journey in pursuit of organizational
excellence.
Evaluation Methods to Assess Organizational Performance Excellence
Organizations participate in quality award processes as a way to support quality
management and gauge the success of their program (Eriksson, 2016). According to
Thurer et al. (2018), performance excellence translates to organizational performance
management with results based on improvement in overall efficiency, effectiveness,
capability, and the successful delivery of value to customers and stakeholders.
Ferdowsian (2016) studied the prominent national excellence and quality frameworks to
identify the major categories found in assessment tool to include (a) leadership
development and excellence model; (b) strategic planning; (c) corporate values; (d)
workforce health assessment; (e) human resource management; (f) customer service and
43
satisfaction; (g) knowledge management; (h) collaboration, (i) decision making and
conflict resolution models; (j) clear, and consistent internal/external communication
systems; (k) continuous improvement and process management teams; (l) ethics and
social responsibility; (m) quality assurance and management; (n) clarity of mission and
vision; and (o) meaningful corporate values and guiding principles. Among the various
quality awards and the evaluation criteria, the recognition for receiving the award is a
testament to a companies' successful QM program implementation and performance
excellence achievement (Eriksson, 2016).
Several quality awards have launched in the last three decades. Dubey (2016)
discovered an increasing interest in business excellence models across business
industries. Thurer et al. (2018) found over 80 awards and highlighted the following
widely used quality and business excellence models: Shingo model for operational
excellence, the Deming Prize, Malcolm Baldrige national quality award (MBNQA), and
the European Foundation for quality management excellence. Research into these
business excellence models reveals similar themes and assessment criteria with minimal
differences. According to Eriksson (2016), the contemporary quality award procedures
includes an examination of the organizations' operations, by examiners or assessors, and
a comparison with an evaluative criterion and scoring convention to determine status
among the highest-scoring finalist for the respective award given.
Shingo model for operational excellence. Thurer et al. (2018) started the Shingo
Prize for excellence in manufacturing to honor Shigeo Shingo. According to Found,
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Lahy, Williams, Hu, and Mason (2018), the Shingo model is used by leaders who want to
propel their organizations’ operational excellence or continuous improvement methods.
The Shingo concept of operational excellence includes five key concepts: (a) aligned
management system and principle-centered culture; (b) principle-driven results that
inform behavior expectations; (c) primary focus on behaviors and results; (d) strategic
use of tools such as Lean, Shigeo Shingo, and TQM to shape ideal results and employee
behavior; (e) principle-centered culture designed to support long term outcomes (Found
et al., 2018).
The Deming prize. According to Breja et al. (2016), the Deming Prize was
established in 1951 to honor Dr. William Deming and his contribution to the statistical
process control method popularized in Japan. The Deming prize is considered one of the
highest awards in quality management and considered similar to the caliber of MBQNA
award winners and the European quality award equivalent. The evaluative criteria for the
Deming prize include categories such as policies, human resources, operations,
information management, quality assurance, improvement, strategic planning, knowledge
management, and ongoing maintenance (Garza-Reyes et al., 2015).
Malcolm Baldrige national quality improvement act (MBQNA). MBQNA
originated in the United States in 1987 to recognize companies for business excellence
achievement and quality in their industry (Lee & Ooi, 2015). Arnold et al. (2015)
described the establishment of MBQNA in 1987 and the award origin after the US
Secretary of Commerce, Malcolm Baldrige, who was known to be a champion for
45
competitiveness and quality in U.S. businesses. Many companies around the world use
the Baldrige criteria as a self-assessment measurement tool, for benchmarking, and to
apply for the award for excellence in business performance (Breja et al., 2016). The most
prestigious federal government quality award program is now known as the Baldrige
Performance Excellence Program (Hallam, Valerdi, & Contreras, 2018). The Baldrige
criteria for performance excellence (CPE) includes a comprehensive program with the
following attributes: emphasis on excellence; systematic management; performance
measurement; thorough training; evidence-based treatment; and employee rewards
(Griffith & Patel, 2017).
According to Schulingkamp and Latham (2015), the healthcare criteria for
performance excellence (HCPE) is a framework for improvement and research findings
support that utilization will result in high performance, improvement in patient
experiences, safety, and efficiency. Healthcare organizations did not become eligible for
the MBNQA until the creation of criteria for the healthcare industry in 1998 (Arnold et
al., 2015). According to the (Baldrige performance excellence, 2019), the criteria for
performance excellence in health care includes following a set of behaviors and beliefs
common in a high-performing organization: (a) visionary leadership, (b) patient-focused
excellence, (c) valuing people, (d) systems perspective, (e) ethics and transparency, (f)
managing for innovation, (g) management by facts and data, (h) organizational learning
and agility, (i) focus on success, (j) delivery of value and results, and (k) contributions to
community health and surrounding society. Baldrige examiners use standard criteria to
46
assess organizations for the performance excellence award, in seven areas critical for
managing and performing as an organization, such as leadership, customer focus,
operations, process management, strategic planning, data collection and analysis, and
business results (Garza-Reyes et al., 2015).
Leadership. Leaders of an organization set the vision, mission, strategic goals,
and initiatives that support the business they operate. Leadership expectations are
communicated to the entire workforce to ensure employees understand the priorities,
cultural norms, and values, and set the tone for the organizational culture. Organizational
leadership is a criterion for evaluation in quality award applications for healthcare
performance excellence. Applications for quality and performance award recognition
begins with questions that assess how leaders govern operations while deploying the
vision and values throughout organizational processes, measures, and goals while
incorporating input from suppliers, stakeholders, partners, workforce, and patients
(Griffith & Patel, 2017). According to Arnold et al. (2015), there is an expectation that
today’s healthcare leaders cultivate an environment focused on continuous improvement
while staying abreast of the management practices that improve learning and employee
development systems in organizations. The leadership category of the Baldrige HCPE
application explains the methods leaders employ to convey the mission, vision, values,
competencies, and strategic goals to the workforce, stakeholders, and patients (Baldrige
performance excellence, 2019). Leadership has a direct impact on process quality,
information, metrics, and data analysis in an organization and is responsible for setting
47
the strategic focus and establishing employee competency standards (Mellat-Parast,
2015).
Strategy. Leaders develop organizational strategies with priorities to provide
direction for the establishment of a strategic planning process, the implementation plan,
and ongoing monitoring of metrics to track progress. Quality award-winning
organizations emphasize the need for leadership direction and decision making through
goals, action plans, and initiatives that have linkages to the business strategy and
customer needs (Hallam et al., 2018). According to Rao (2016), there is a new soft
leadership paradigm in organizations with expectations that leaders set goals, build strong
teams, motivate, and recognize employees when they achieve company goals and
objectives. The company goals should have strategic goals that directly link to customer
needs (Lengnick-Hall, 1996).
Customers. Customers’ focus is a key area of emphasis for organizations pursuing
performance excellence. The goal of customer focus is to illustrate how an organization
addresses stakeholder and customer expectations through customer engagement activities
and the voice of the customer (Schulingkamp & Latham, 2015). Organizations seeking
quality recognition demonstrate how they solicit feedback in policies and practices while
emphasizing employee training to satisfy stakeholders’ and patients’ desires or needs.
Afthanorhan et al. (2019) defined customer satisfaction as the level of quality service that
reaches a customer’s expectation. According to Schulingkamp and Latham (2015),
patient and stakeholder satisfaction are two key measurements that hospitals compare
48
their data against competitors.
Performance measurement and analysis. According to Hewko and Cummings
(2016), performance measurement and analysis is the development and maintenance of
processes and systems that measure outcomes and monitor results. Performance measures
and analysis include data that inform the status of core procedures and systems that
produce services or products for customers (Baldrige performance excellence, 2019). The
workforce efficiency and effectiveness in operations improve when employees engage
with leaders to examine how work processes evolve to offer a quicker or better quality
product and service (Evans & Davis, 2015).
Workforce. According to Arnold et al. (2015), in organizations with a high-
performing workforce, management emphasizes developmental learning, agility,
openness to change, and fosters a culture of continuous improvement. Examiners, who
evaluate organizations for quality award recognition, ask leaders to explain their process
for assessing the capacity of the workforce, hire new employees, manage change, engage
the workforce, and develop employee careers. The MBNQA criteria for the assessment of
employee development and staff learning includes content about organizational core
competencies, ethical business practices, knowledge management, and short- and long-
term action plans to achieve strategic goals.
Operations. Found et al. (2018) defined the origin of operations from a
description of expending labor on activities within a business. Operations management is
a common area of evaluation within quality award performance criteria. According to
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Schulingkamp and Latham (2015), the operations addresses overall process design,
management, improvement, and overall work systems. Organizational leaders should
know how their company manages, improves, and innovates health care services and
work processes that serve the patient while achieving success (Baldrige performance
excellence, 2019).
Organizational results. Organizational results detail a company’s deliverables,
which account for healthcare outcomes and other process results. Parast and
Golmohammadi (2019) opined that when leaders implement changes in pursuit of
excellence in healthcare, they restructure and design systems, processes, and services that
center on the patient. The MBNQA framework measures leaderships’ ability to empower
their workforce to achieve goals and outcomes with superior results while continuously
improving service delivery (Lee & Ooi, 2015). Leadership vision and organizational
direction are critical for the results of products or services rendered in a business (Peng &
Prybutok, 2015).
There has been extensive research of the MBNQA framework and results support
the belief that when adopted, the business performance model will assist company leaders
with overall performance improvement within their organizations (Lee & Ooi, 2015).
There are common behaviors and norms found in organizations that have won the
Baldrige award for performance excellence and other quality awards. In a study
conducted by Griffith and Patel (2017), Baldrige recipients practice the following actions:
(a) explicit commitment to values and mission, (b) a culture of empowerment, (c) top-
50
down and bottom-up strategic goals and planning, (d) performance measurement and
monitoring, (e) systematic continuous improvement, (f) extensive training, (g) evidence-
based protocols, and (h) a robust employee recognition program.
European Foundation for Quality Management Excellence (EFQM).
Excellence is described as strategies, best-in-class performance, and outstanding practice
in the management of an organization and business results (Breja et al., 2016). According
to Garza-Reyes et al. (2015), the EFQM award allows an assessor to evaluate companies
on their status in the areas of leadership, people management, resources, process,
business results, policy, strategic planning, customer satisfaction, employee satisfaction
and impact on society. Companies that wish to implement a business excellence model
can use EFQM as a model approach to introduce a culture of continuous improvement
and a culture of quality (Gómez, Costa, & Lorente, 2017). The EFQM, Deming prize, and
MBNQA business models share similar themes, criteria, an emphasis on continuous
improvement and process management (Garza-Reyes et al., 2015). Leaders from the
various business sectors apply for evaluation and assessment of these prominent
performance excellence award programs.
Healthcare Studies of Improvement and Organizational Excellence
In a study of quality in a healthcare delivery system, Adams et al. (2015) observed
the leaderships' approach to quality of care improvement initiatives involved the use of
assessment teams lead by a quality consultant group. Team support from leadership
includes training, coaching, leadership feedback, and ongoing attention. According to
51
Adams et al. (2015), a consultant group supported leadership, and unit-based teams
created a supportive infrastructure inclusive of coaching, quality training, and facilitative
meetings to ensure alignment with organizational goals while efficiently driving
improvement using appropriate quality tools and techniques. The leaders of a healthcare
system should complete extensive quality training to champion improvement projects and
facilitate change management efforts. Leadership involvement with teams is considered a
critical success factor for the successful use and integration of any quality management
approach (Ismyrlis, 2017).
Another study of hospitals’ use of quality management approaches, revealed
different results in patient outcomes and patient satisfaction scores (Branco et al., 2017).
Relational issues among improvement teams may occur as team members understand
problems differently, disagree on the initial losses, and share the commitment to a newly
designed process (Baker, Suchman, & Rawlins, 2016). Chartering teams with leadership
support and consultative quality management experts can lead to the enhancement of
process, procedures, and overall operations throughout a company to ultimately achieve
organizational performance excellence (Adams et al., 2015).
Healthcare organizations need to adapt to a rapidly changing environment where
technological growth outpaces the practice of medical protocols. Arnold et al. (2015)
stated that leaders in healthcare should elicit high performance to adapt to the rapidly
changing environment and foster employee learning for continuous improvement.
Leaders and employees alike should engage in organizational performance improvement
52
initiatives. Excellence in health care requires an organizational and individual
commitment to providing timely quality care and team coordination in an environment
that cultivates the integration of teams and solid work processes (Griffith & Patel, 2017).
Transition
In section 1 of the study, I included information about the challenges of healthcare
leaders to provide quality medical care effectively and efficiently while achieving
excellent performance results. I explained the background of the problem, problem and
purpose statements, research and interview questions, and the nature of the study. I
discussed the conceptual framework, key operational definitions, assumptions,
limitations, and delimitations of the study. Lastly, I reviewed, analyzed, and synthesized
articles from the review of professional and academic literature in specific areas to
include the selected conceptual framework, supporting and contrasting theories, quality
management approaches, leadership engagement in quality activities, organizational
performance excellence, and evaluation methods to assess organizational performance
excellence.
In Section 2, I present the proposed research project to include the purpose of the
study, the role of the researcher, research method, and design. I will discuss population
sampling, ethical impact, the collection of data, data analysis, reliability, and validity. In
Section 3, I will discuss the research findings, including a review of the general research
question. The presentation of findings from the data collection, analysis, and
identification of themes will conclude the study.
53
Section 2: The Project
The purpose of this qualitative, single case study was to explore strategies that
hospital leaders use to employ quality management approaches effectively to improve
processes and achieve organizational performance excellence. Researchers who utilize
the descriptive case study design detail in-depth research of lived experiences in the
actual environment (Fusch & Fusch, 2015). In Section 2, I will address information about
the purpose of the study, the role of the researcher, participants, research methodology
and design, sampling, ethical research, data collection, and transition to the last section.
Purpose Statement
The purpose of this qualitative single case study was to explore strategies that
hospital leaders use to employ quality management approaches effectively to improve
processes and achieve organizational performance excellence. The target population was
five leaders within a hospital located in a community hospital in the northeast region of
the United States that have successfully leveraged quality management tools and
techniques to improve healthcare delivery. The findings from this study may contribute to
social change through the improvement of healthcare delivery, resulting in a healthier
patient population and community.
Role of the Researcher
I was the sole researcher for this qualitative single case study. The definition of
research is the act or activity to test a hypothesis or develop new knowledge in an
existing context (Haylett, 2009). According to Santos et al. (2017), researchers should
54
avoid situations that pose a conflict of interest, result in unethical practices, or
demonstrate bias in a study. The Belmont Report was a response to unethical practices in
research and contained a framework for researchers to follow (Haylett, 2009). It was my
responsibility to complete research by interviewing participants and reviewing
documentation in an ethical matter, without conflicts of interest while managing bias. I
conducted interviews, made personal observations, examined pertinent organizational
documents about their quality program, and conducted semistructured interviews with
participants.
A researcher should conduct interviews and review documents responsibly while
ensuring ethical practices by taking steps to mitigate risks to participants while avoiding
bias (Nebeker, Linares-Orozco, & Crist, 2015). The principles in The Belmont Report
include respect for persons participating in the research project, justice for each
participant devoid of underserved benefit, and fairness for each participant (Haylett,
2009). To fulfill the principles in The Belmont Report, I conducted interviews responsibly
through autonomous interviews. I ensured that each participant’s engagement was
objective and fair by asking the same interview questions of each participant. The
Institutional Review Board at Walden University oversaw and approved my plans for this
study before I conducted any collection of data.
As the data collection instrument, the establishment of controls was vital to avoid
researcher bias. I am a quality manager working in the federal government, in an area of
regulatory oversight, and my experience with QM approaches, tools, and techniques,
55
caused a strong potential for bias, assumptions, and misinterpretations. According to
Reichow, Barton, and Maggin (2018), sources of bias include misunderstanding data,
mechanical error, delays in data collection, variability in interview sessions with
researcher, and holiday or seasonal breaks in research. I mitigated the risk of bias through
the use of rigorous data analysis, a consistent protocol (see Appendix A) during
interviews, and company document review. The use of open-ended responses mitigates a
researcher's resistance to examining data through a personal lens (Yin, 2017). East (2015)
stated that researchers could avoid aspects of bias by ensuring there are no limits on the
interpretation of findings or selective highlights of the information shared. Further actions
can be taken to manage bias, including the timely completion of research data analysis to
avoid misinterpretation, establish agreements such as conflicts in interest, informed
consent, and statement of financial support.
Participants
According to Yin (2017), participants are persons from whom the researcher
collects data through observation, interviews, or review of case study reports. I
interviewed five healthcare leaders who are executives within a hospital that have
successfully demonstrated the use of quality management approaches to improve
processes and achieve organizational performance excellence. To identify the appropriate
healthcare leader participants, I contacted a U.S. federal organization that manages,
facilitates, and examines organizations that apply for national recognition for quality and
performance excellence in the healthcare category for recommendations. Saunders et al.
56
(2019) advised researchers to prepare for participant interaction by considering how to
manage cultural reflexivity, which includes determining whether to conduct interviews
separately or as a group. I conducted this qualitative case study through individual
interviews, took field notes of my observations from study participants, and reviewed
organizational documents that explained the organizational policies and processes for
quality planning, strategic planning, performance measurement, process improvement,
performance excellence evaluation, customers, and key processes.
In preparation for the study, I contacted participants through an organizational
point of contact, using a letter of invitation explaining the purpose of the research. I
established a working relationship during the planning stage to conduct interviews. To
prepare for interviews, I reviewed the informed consent form and used an interview
protocol to guide the progression of inquiry to capture pertinent data to inform participant
answers to the research and interview questions related to the purpose of the study (see
Appendix A).
According to Wengraf (2001), the research interview improves knowledge from
conversational interaction as the researcher asks semistructured, scripted questions (see
Appendix B) as a primer that should trigger additional commentary participants want to
share. I gained access to hospital leaders through an assigned point of contact, through a
request during the initial engagement with the hospital administration. According to
Marshall, Klocko, and Davidson (2017), participants may feel unclear about expectations
during initial interactions due to the lack of planning information. Gaining access to
57
participants through electronic mail and phone calls confirmed that the appropriate
people from the hospital participated in interviews and were verified using the criteria for
participant selection.
Researchers develop a selection criterion for participant identification to ensure
the appropriate individuals participate in the study (Lockwood, Munn, & Porritt, 2015).
The criteria for participants included their organizational role as an executive or senior-
level leader within the health care system of interest, experience with quality
management approaches, and at least a year of experience at the current hospital as a
member of leadership during the time of the application and evaluation for performance
excellence recognition.
Research Method and Design
I used the qualitative research method to conduct a single case study to discover
how healthcare leaders successfully leverage QM approaches to achieve organizational
excellence. According to Saunders et al. (2019), researchers use the qualitative research
method to interpret and make sense of the subject of study in their natural setting to
appreciate the more in-depth understanding. I used the qualitative methodology to
conduct this study as I examined leaders in their environment to make observations and
conduct semistructured interviews.
Research Method
The use of a qualitative research method is viewed as interpretive because
researchers explore subjective meanings about the behaviors and experiences under study
58
(Saunders et al., 2019). According to Park and Park (2016), the focus of qualitative
research involves gaining meaning or understanding of an experience. I interviewed
hospital executives to gain an understanding of the ways they use QM methods and tools
to achieve performance excellence throughout medical programs and healthcare delivery.
A researcher's approach, using the qualitative method, should be flexible and evolve to
explore meaning through interviews (Jamali, 2018).
Researchers that conduct quantitative research leverages the use of numerical data
from a highly structured collection technique (Saunders et al., 2019). The methodological
foundation of quantitative studies test hypotheses through statistical analysis (Ridder,
2017). For this study, I used non-numerical data collection through semistructured
interviews. I did not plan to test a hypothesis during this study and did not use a
quantitative method.
Morgan (2015) stated that quantitative variables and qualitative themes are in use
in mixed methods research. The design of mixed methods research includes qualitative
data collection techniques with quantitative analytical procedures (Saunders et al., 2019).
Researchers use mix methods when a study includes quantitative data as a primary source
and qualitative data as the secondary informational source (White & Miller, 2019). I did
not use mixed methods for this study because I did not study variables.
Research Design
The research design of this study was a single case study with semistructured
interviews, the review of interview notes, the review of organizational documents, and
59
direct observations of hospital leaders in their environment to explore their strategies to
leverage QM tools to pursue excellence within their organization. Yin (2017) detailed
four types of single case study: a single case with holistic design, a single case with an
embedded design, multiple cases with holistic design, and multiple cases with embedded
design. I conducted a single case study with a holistic single-unit of analysis. Ridder
(2017) stated that a single case study design is ideal and justifiable, where a case
represents a critical test of the existing theory. Researchers use the case study design to
explore patterns and meaning in a particular context (Radley & Chamberlain, 2012).
There are three types of qualitative research design I considered for this study:
phenomenological, ethnographical, and case study. According to Goad and Jones (2017),
researchers will conduct a phenomenological study to focus on making meaning of lived
human experience to uncover and interpret cognitive processing to reveal the
understanding of a phenomenon. In contrast, Kegler et al. (2019) stated that researchers’
use of the ethnography design to examine culture over time with continuous observation,
while building rapport with the surrounding community. I did not study the culture of the
organization over time nor did I study leaders to uncover the cognitive processing of a
phenomenon. I did not consider ethnographical and phenomenological designs
appropriate for the study. Ridder (2017) explained that researchers conduct case studies
to explore the real-life phenomenon of a group, organization, event, or individual
resulting in deep description and insights.
According to Yin (2017), there are three case study types: exploratory,
60
explanatory, and descriptive. During the exploratory case study, the researcher explores
what is occurring to ascertain insight about a topic of interest through what or how
questions (Saunders et al., 2019). I interviewed hospital leaders to understand how they
use QM approaches in their pursuit of organizational excellence resulting in the Malcolm
Baldrige quality award recognition in healthcare. According to Flynn and Hartfield
(2016), the use of thematic analysis to examine each interview may result in the
discovery of key statements, meaning, and group themes from the data. According to
Cairney and St. Denny (2015), when interviewees are unable to explain, directly
observing behavior in their natural environment may reveal additional information.
Researchers conduct explanatory case studies to seek answers to questions that
explain presumptions and causal links to real-life experiences (Baxter & Jack, 2008). An
explanatory research study is useful when researchers are explaining how or why a
condition, event, or a sequence of events happen (Yin, 2018). According to Saunders et
al. (2019), researchers use explanatory studies to explain a situation and to explore the
relationships between variables.
Yin (2017) defined the purpose of a descriptive case study as an effort to describe
a phenomenon in its real-world context. Diaz-Correa and Lopez-Navarro (2018) defined
descriptive case study research as an analysis of a phenomenon through the use of a
theoretical framework. Researchers use descriptive case studies to gain an accurate
account of events, situations, or persons through who, what, when, how, and why
questions (Saunders et al., 2019).
61
I achieved data saturation by conducting individual interviews until there was no
discovery of new themes or subthemes. According to Fusch and Fusch (2015), failure to
achieve data saturation in research has an impact on the validity and the quality of data
collection. Hancock, Amankwaa, Revell, and Mueller (2016) stated that the novice
researcher might achieve the gold standard of data saturation when there are no new
emerging themes, and the research findings permit transferability. In addition to
conducting interviews and reviewing multiple sources of data, I triangulated data from all
methods of data collection used during this study. Yin (2017) stated that data
triangulation from multiple sources of evidence allows the researcher to produce valid
results. Observation and review of company documents about quality planning, strategic
goals and objectives, performance measurement, audits, and internal assessments
provided additional data to compare themes and subthemes. The selection of the
appropriate participants informed adequate sampling to explore the research and
interview questions.
Population and Sampling
The population studied was executive healthcare leaders who successfully used
QM approaches in their company to achieve organizational performance excellence.
According to Stuart and Rhodes (2017), determining the target population is a critical
step and will depend on the questions of interest during the study. Leaders shape the
vision, mission, and strategic focus of an organization and are the best population to
interview and explore QM methods in use to achieve superior outcomes (Anderson &
62
Jamison, 2015). Cairney and St. Denny (2015) advised that once a researcher decides to
conduct interviews, the next steps are the selection of individuals who will be researchers'
sampling size and the appropriate sampling method.
The target population and sampling size for this study included five executive-
level healthcare leaders with a history of successfully using QM methods to achieve
performance excellence. Purposive sample selection is a method that researchers utilize
to identify samples using specific criteria that is not random (Olsen, Orr, Bell, & Stuart,
2013). I purposively selected the population after I identified hospitals that were awarded
performance excellence recognition in the past 10 years and consulting with the executive
director of the federal government organization that assesses applications for the national
quality award, Baldrige. According to Saunders et al. (2019), non-probable sampling
includes a range of techniques to select participants of business research, case study
research, or market surveys. Yin (2017) defined the purposive selection of a case to
understand further or to illuminate the use of theoretical concepts. The use of purposive,
homogeneous sampling in case study research focuses on a group, level, or occupation in
an organizational hierarchy (Saunders et al., 2019). I ensured data saturation by focusing
attentively on the emergence and depletion of new data and themes to code from
interview participants, field notes, or company documents.
I worked with an organizational point of contact from the site to identify and
request hospital executives that fit criteria that included at least one year in a leadership
position in the organization, direct involvement in hospital operations, process
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improvement, and performance measurement. Once I identified prospective participants,
I contacted them via electronic mail, explained the research and nature of the study, and
completed planning to interview them in an office within the hospital. I requested an
interview setting that was private, comfortable, and within a reasonable walking distance
of each interview participants’ office. Jenner and Myers (2019) opined that interview
settings that are convenient for participants, private and in-person, result in more sharing
of experiences.
Ethical Research
I followed Walden University policies and procedures to obtain approval from the
institutional review board (IRB) before contacting the prospective participants in this
study. According to Perrault and Keating (2018), the IRB reviews and approves the study
and the informed consent form to ensure that the researcher will conduct an ethical
research project. Researchers should follow the basic ethical principles from the Belmont
Report: (a) respect for persons, (b) beneficence, and (c) justice (Haylett, 2009).
The informed consent process includes a requirement for study participants the
time to review relevant information about the research before obtaining their agreement
to participate (Cooper & McNair, 2018). In addition to informing participants of their
rights and the process, researchers should ensure individuals participating in research
know that they can withdraw at any time (Perrault & Keating, 2018). Haylett (2009)
discussed the general principles in the Belmont Report for individuals participating in
research projects to include prevention of a lack of underserved benefit while ensuring
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fairness. I asked study participants to review and complete an informed consent form
which outlined the process and provided relevant information about the research. The
invitation letter to participants included instructions for participants should they wish to
withdraw from the study and any stage. There was no incentive to participate in the
study. I used available templates from Walden University to develop documents and
obtained the necessary approvals before conducting data collection for the research study.
All records that I created for the study will remain secure in a safe and will remain
in a personal drive for 5 years following the completion of the research. I will destroy all
research documents by shredding, after the 5-year requirement, to maintain
confidentiality. In addition to securely storing research documents, I assigned codes such
as IP1, IP2, and IP3 instead of names to protect the privacy and confidentiality of the
organization and participants in the study. According to Kirilova and Karcher (2017),
assigning codes to interviewees and locations is one way a researcher can apply broad
logic to deidentify participants. The final document will not include the names of
participants or the company where they are employed. Walden University IRB approval
number for this study: 10-25-19-0676189.
Data Collection Instruments
I served as a data collection instrument for this study. I used an interview protocol
(Appendix A) to conduct semistructured interviews, reviewed company policies, and
other organizational documents while ensuring reliable data gathering through member
checking and data triangulation. Ridder (2017) emphasized that traditional case study
65
design includes interviews as the primary and most important data collection source. A
researcher conducts semistructured interviews with a ready list of questions and will
often ask follow-up or probing questions during the discussion (Chu & Ke, 2017; Goad &
Jones, 2017).
I used interviews, observation, and secondary sources to gather data and other
useful information discovered during the study that is relevant to the overarching request
question. Researchers will use multiple methods of data collection when conducting
qualitative studies (Park & Park, 2016). According to Kegler et al. (2019), the researcher,
who serves as the data collection instrument, will use more than one of the following
collection techniques to obtain data during the study: (a) focus groups, (b) interviews, (c)
photovoice, (d) observation, and pulling information from secondary sources. A
researcher may use a variety of interview approaches such as telephonic, online
questionnaires, face-to-face interviews, focus groups, and panels (Zhang et al., 2017).
After interviews, I asked participants to review summaries to clarify information
in follow-up meetings via email. Goad and Jones (2017) stated that member checking and
peer debriefing are two methods to ensure the trustworthiness and quality of data
collection. According to Ridder (2017), the review of documents, observations, and
interview responses are data the researcher will use in combination to ensure reliability
through data triangulation.
Data Collection Technique
The primary data collection technique for this study was semistructured, face-to-
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face interviews in a location that the participants selected. I used an interview protocol
(Appendix B) to guide interviews with participants. According to Yin (2017), interviews
are the most important aspect of case study research. An interview is an excursion into
the life of the respondent to discover the phenomenon under study (Ridder, 2017).
Cairney and St. Denny (2015) stated that although the research question and conceptual
framework shape a case study, the progression and exploration facilitates the information
that the researcher gathers during interviews. There are risks when considering the use of
interviews as the primary data collection technique in a study.
Ridder (2017) described case study design as the catch-all category for research
that does not fit into any other method while attributing a negative connotation about
using case study research that explores differences and similarities across multiple cases.
Yin (2017) described weaknesses from interview evidence such as respondent and
participant bias, reflexive responses from respondents, and inaccuracy in the
interpretation of interview responses. Determining the adequate number of interviews to
conduct for data quality and depth for a research study continues to be a challenge for a
qualitative case study (Cairney & St. Denny, 2015). Saunders et al. (2019) posited that
data collection obtained primarily from participant interviews is devoid of context that
leads to understanding views and the cultural environment. When there are challenges
and complexities to planning research data collection, a pilot case study may be
conducted to formulate the final protocol (Yin, 2017).
I did not conduct a pilot case study for this research project because I prepared
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participant interview questions to support the overarching research question. Researchers
conduct pilot case studies when an extensive relationship occurs with the participants in
the actual case. According to Yin (2017), a researcher might conduct a pilot case study to
assist with the formulation of questions and for convenience, access, or geographical
proximity. The interview protocol (see Appendix A) for this study prompted questions
about the organizations' pursuit of performance excellence in a healthcare setting. I
identified and selected the target population after I identified a healthcare organization
with national recognition for healthcare delivery, performance excellence, and customer
satisfaction results.
I continuously reviewed data collected from the study, transcribed interview
responses from participants and followed up with additional or clarifying questions as
necessary. Baxter and Jack (2008) stated that researchers should collect and analyze data
while integrating member checking procedures to verify participants’ agreement with
accuracy and the interpretation of responses. According to Goad and Jones (2017),
researchers can attest to the trustworthiness of interview data through member checking
and debriefing. Saunders et al. (2019) explained that the procedures for participant
validation of interview data collection include sending information back to participants to
confirm the accuracy and capture corrections. I organized and maintained data relevant
for this study and stored information in a secure location.
Data Organization Technique
To keep track of data collected from the study, I maintained journals, recordings,
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and research logs. All hard copy records and documents that I obtained from the
participating organization will remain secure in a safe with electronic storage of
information on a personal hard drive for 5 years following the completion of the research.
I will destroy all research documents, after the 5-year requirement, to maintain
confidentiality. Information gathering strategies a researcher might use during the data
collection phase includes field notes, peer-to-peer data examination, and reflection
journals (Baxter & Jack, 2008). Yin (2017) identified the following sources of evidence
and data collection in a case study: (a) participant observation, (b) interviews, (c)
documentation, (d) physical artifacts, (e) archival records, and (f) direct observation. I
anticipated the accumulation of interview data, field notes of my observations, company
documentation, and archival records during my study. I secured copies of all documents
relevant to my study, at all times, in a locked briefcase and password-protected laptop.
According to Saunders et al. (2019), the collection of primary and secondary sources of
data acquired during research may trigger the early analysis to determine if additional
information is necessary to answer the research question and achieve data saturation
satisfactorily. In my early analysis of the data, I secured both hard and electronic copies
of the materials I accumulated during the interview process.
Data Analysis
Interviews, direct observation, archival records, and documentation are the
multiple sources of data used in this study to find answers to the overarching research
question. During and after data collection, I analyzed data by developing a strategy using
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the principles and methods appropriate for qualitative case study research. The analytic
strategy included evaluating the research data to look for early patterns and tabulating the
frequency of significant occurrences. According to Yin (2017), the following four
principles are applicable when using computer software in case study research: (a) using
multiple sources of data, (b) creating a database to capture data from the study, (c)
maintaining a rigorous chain of evidence, (d) prudent use of data from electronic sources.
After collecting data from this study, the analysis plan included the process for
examination: triangulation, identifying themes, and coding.
Triangulation of different and independent sources of data assists researchers in
confirming the outcomes from data analysis (Saunders et al., 2019). Yin (2017) discussed
the following types of data triangulation in case study research: (a) theory triangulation,
(b) data triangulation, (c) methodological triangulation, and (c) investigator triangulation.
I considered two of the four triangulation methods for this study: methodological and
data. Methodological triangulation is a type of data analysis that allows a researcher to
evaluate multiple sources of data to explore the effectiveness of programs (Drouin,
Stewart, & Van Gorder, 2015). Kern (2018) defined data triangulation as a subdivision of
data across space, time, and people. Yin (2017) described data triangulation as a
corroboratory strategy to compare similar findings from the various data sources. The
early analysis of data from participant interviews, records, documents, and direct
observations from this study influenced my approach to triangulation based on findings.
The review of academic and professional literature for this study was the primer
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for the preliminary themes or theoretical propositions that link to the conceptual
framework, topical area, and industry. The data collection plan for this study included
capturing notes from the interviews, transcripts, archival documents, and direct
observations to associate with the preliminary themes and identify other emerging
themes. As I continued data collection and linked information to themes, I compiled the
information using NVivo software to assist me in analyzing the data from the various
sources. The use NVivo 12 software version aided in my identification of certain words
and key phrases to eventually map and identify key themes. Swygart-Hobaugh (2019)
opined that data analysis software could assist the researcher by enhancing the coding
process and identification of themes. Yin (2017) described three process steps when
using computer software to manage data: (a) compile the data, (b) disassemble the data or
identify themes, and (c) reassemble the data. I correlated the themes found in this study
with the professional and academic literature, the conceptual framework, and any recent
study publications while writing this prospective study. The use of thematic
categorization was useful in the presentation of findings, study recommendations,
implications for future research, and study conclusions.
Reliability and Validity
Reliability
Reliability in research design refers to the ability to replicate an earlier research
method and design to achieve similar or the same findings (Saunders et al., 2019).
According to Yin (2017), reliability is a demonstration that data collection procedures
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and other operational aspects of a study a new researcher can replicate with equal to
minimal error and bias. I addressed the dependability of this study by member checking
summary responses to the interview questions from the protocol (Appendix A).
Organizational documents, data collection, data analysis, and observational field notes
detailed the information I collected during interviews. According to Abdalla, Oliveira,
Azevedo, and Gonzalez (2018), reliability is linked to the credibility of a study as the
presence of both is evident through the successful triangulation of multiple data sources.
Fusch and Fusch (2015) opined that triangulation is a way to ensure data validity.
Validity
I established the validity of this study through the quality of data collection,
accuracy of analysis and interpretations, and the general report of findings. Saunders et
al. (2019) defined research validity as the appropriate measurement, accuracy of data
analysis, and the generalizability of results findings. Transferability, confirmability, and
saturation of data are the components that researchers use to demonstrate research
validity. Gill, Gill, and Roulet (2018) explained that transferability is the extent to which
a researchers’ findings can be of use from one context to another with a relatively close
degree of fit. To ensure transferability, I provided detailed explanations of the interview
protocol, the criteria for participant selection, the conceptual framework, and the relevant
concepts in the literature from my study. Confirmability is the measure taken in research
to assure conclusions drawn in the summary of findings are from the participants and
without biased accounts from the researcher’s perspective (Abdalla et al., 2018). To
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assure confirmability about this study, I triangulated data from all sources gathered
during the study to include interview summaries, company documents, field observations,
and archival records. Failure to achieve data saturation negatively impacts the validity of
researchers’ findings (Fusch & Fusch, 2015). To reach data saturation, I interviewed
multiple leaders from the same organization using the same interview protocol (Appendix
A). I leveraged data from participant responses and triangulated data from company
documents and archival records to identify the key themes used in the discussion of
findings in the final section.
Transition and Summary
In Section 2, I explain the research project proposal to include the purpose of the
study, the role of the researcher, research method, and design. I discuss population
sampling, ethical impact, data collection plan, data organization, data analysis, reliability,
and validity. In Section 3, I discuss my findings to answer the general research question. I
present findings from my data collection, analysis, identification of themes, application to
professional practice, implications for social change, recommendations for future
research, reflections about the doctoral process, and a conclusion.
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Section 3: Application to Professional Practice and Implications for Change
Introduction
The purpose of this qualitative single case study was to explore strategies that
community hospital leaders used to effectively employ quality management approaches
to improve operations and achieve organizational excellence. To collect data and
information about quality management strategies that leaders leverage in pursuit of
excellence, I conducted semistructured interviews with five experienced hospital
executives. These five executives met the criterion that included employment in a health
care delivery system with the distinction of excellence as determined by the U.S.
Presidential Quality Award through the Baldrige Performance Excellence Program in the
health care sector. The administration of the Baldrige award program is through the
National Institute of Standards and Technology (NIST) for organizations that
demonstrate holistic organizational excellence.
I traveled to each executive's place of employment to conduct interviews, review
company documents, and journal field observations. I reviewed company documents such
as standard operating procedures, organizational performance metrics, action plans, and
other project documents. Through data analysis and triangulation, I identified the
following themes: (a) measurement and analysis for performance improvement, (b)
strategy and strategic planning, (c) leadership direction, sponsorship, and engagement, (d)
employee engagement and empowerment, and (e) resource management. In this section, I
will present the findings from my study, discuss applications to professional practice, the
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social change impact, and provide recommendations for actions and future research.
Finally, I will reflect on my experience throughout this doctoral process before
concluding the study.
Presentation of the Findings
The overarching research question for this study was: What strategies do leaders
use in community hospitals to effectively employ quality management resources to
improve operations and achieve organizational excellence? To explore and answer the
overarching research question, I interviewed five healthcare executives of one healthcare
delivery system that has successfully achieved and sustained organizational performance
excellence while receiving national recognition through the Baldrige Performance
Excellence Program in healthcare. The participants in this case study were all healthcare
executives employed at the partner organization involved in this research project, which
is a community hospital located in the northeast United States.
Each participant’s identity in the presentation of findings will remain confidential
and labeled as IP1, IP2, IP3, IP4, and IP5 to preserve their privacy. During the
interviews, I utilized ADA dictation application software to convert audio speech to text
and Microsoft Word to prepare and transcribe the data. I used NVivo 12 software to assist
in the coding, categorization, and data analysis to identify themes. I triangulated data,
stemming from exact words and phrases, from the interview transcripts, company
documents, and field observations to identify the following prevalent themes that
describe leadership strategies to achieve organizational excellence: (a) measurement and
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analysis for improvement, (b) strategy and strategic planning, (c) leadership direction,
sponsorship, and engagement, (d) employee engagement and empowerment, and (e)
resource management.
Theme 1: Measurement and Analysis for Performance Improvement
Each interview participant highlighted the importance of measuring performance,
analyzing performance data for core programs and procedural areas, and improving when
opportunities are discovered. The participants discussed the importance of measuring
outcomes and comparing outcomes with similar organizations to determine if
performance exceeds or meets the standard of care in a respective area. Interview
participant number one (IP1) indicated that the organization’s leaders define performance
excellence as the outcomes ranked in the top 10% among any similar organizations
providing a type of service. IP1 noted, "how do you know if your procedures and
performance outcomes are the best?" IP2 stated that benchmarking against the best of
healthcare industry performers is the only way to determine if their organization is among
the highest performers in specific areas of patient care. IP2 also stated that organizations
must look at performance goals and metrics regularly to cultivate an environment of
excellence and continuously improve based on indications of goal achievement. All
participants described the committee review process in their organization and the
frequency in which they review performance data at intervals of iterative improvement,
confirming the sustained performance, and informing strategic planning initiatives in
successive quarters and years. Table 1 provides the key terms that link to measurement,
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analysis, process, and performance improvement from all the interview participants.
Table 1
Measurement and Analysis for Performance Improvement
Reference Frequency Weighted percentage Similar words
Performance
79
1.45
---
Improvement 78 1.43 improve
Process 59 1.08 processes
Benchmarking 59 1.08 outcomes, benchmark
Analysis 50 1.00 measure, analyze, assess
Goals 38 0.70 initiatives
Performance metrics are useful for leaders who evaluate current organizational
performance, search for the root of medical problems, target improvement in operations,
and to monitor performance over time (Horvat & Filipovic, 2020). Thornton, Tooher,
Ogle, von Dadelszen, Makris, and Hennessy (2016) stated that benchmarking is a proven
method to examine the quality of healthcare when the data is provided and allows
providers to make improvements when they find opportunities for improvement. IP1
discussed the various benchmarking tools in use for tracking financial and clinical data
and how the use of these data sets allowed the leaders to identify areas of most significant
improvement. IP2 describe the use of supplemental data from government and national
databases for benchmarking when direct data is not available. IP3 highlighted the
importance of benchmarking and described it as a process to help define performance
across the organization and ultimately indicate excellence. IP4 stated that benchmarking
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is how they determine if they are performing at a higher level when comparing to peer
groups in healthcare. IP5 opined that benchmarking is the only way to know that you are
successful or performing at a level that is in the top decile of peers or at a higher level of
excellence in specific clinical areas.
Data collection of process and outcome metrics are indicators for managers about
the status of process and program efficiency and effectiveness. The establishment and
continued collection of quality measurement data are of extreme importance to increase
the value of care provided to patients (Chawla & Darlow, 2018). IP1 described the
organizational approach to reviewing metrics and goals repeatedly through various
councils, committees, and leadership meetings. IP2 detailed the various metrics and data
collected that align with the organizational pillars. For example, there is a metric to
collect training and educational data because of the strategic pillar for the workforce. IP3
highlighted the organizational approach to constant improvement through visual
department boards that list goals and metrics specific to each work area. IP4 emphasized
how leaders use the visual display boards to track and measure effectiveness and identify
issues when the data trends in the wrong direction. IP5 explained how the data
measurement and analysis efforts to recognize opportunities for improvement trigger the
performance improvement framework in use across the healthcare system.
IP4 discussed the performance improvement framework used within the
organization that includes activities that cascade through committees from the senior
leadership quality management review committee. IP4 described the various quality tools
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such as Plan-Do-Check-Act (Shewhart cycles) and Six Sigma DMAIC model to charter
improvement actions when they discover opportunities through the various scorecard
metrics, and performance improvement (PI) showcases found in every department. All
participants emphasized the existence of the PI initiatives in every department that
cascade down to individual employees assigned in the respective work areas. IP5
described the collective measure of scorecards, performance data, and overall alignment
of processes to the mission of the health care system and the refreshment of annual
strategic goals. IP5 explained how organizational leaders review metrics, at every level of
the system, and how they are held accountable to demonstrate that performance projects
are meaningful, advance the mission, and improve the overall satisfaction of the patients.
All participants described a constant review of critical areas of focus and the processes
for which they are considered the business owners’ and champions’ responsibility to
engage with staff across the workforce to ensure successful outcomes. The organizational
documents that describe the procedures for the leadership system and the strategic
planning process include graphics and descriptions that explain how the pillars and goals
cascade from the mission and across phases of deployment and implementation.
Linkage to the extant literature. Nadziakiewicz and Mikolajczyk (2019) stated
that to assess the quality of medical care, you must use indicators and criteria that connect
to specific standards. High-performance hospitals develop and sustain an operational
strategy of tracking and reporting metrics in both clinical and financial areas that inform
overall performance to compare to peer organizations. Stan (2018) stated that leaders
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must institute mandatory steps to achieve high efficiency and excellence, including
attentive analysis of practices and a plan to measure to improve performance.
Chakraborty and Kaynak (2018) highlighted the relationship between organizational
process-level performance and the quality management practices present in a hospital.
Organizations that employ a robust strategy to continuously review performance metrics
and full implementation of a quality management system may out-perform their
competitors due to a rigorous and disciplined focus on the daily performance of business
processes taking place in the delivery of healthcare to the patient population served.
Chakraborty and Kaynak (2018) found a strong correlation in hospitals with excellent
outcomes in patient care, high-performing teams, and a system of tracking quality
performance. According to Tickle et al. (2016), organizations with business excellence
perform well above their competitors and ensure the vision, mission, and performance
expectations are communicated and understood by all employees with regular reviews to
ensure sustained success. The participants and their company documents revealed the
existence of systems to track, monitor, and trend data to indicate ongoing performance
and staff with specific training in quality, process improvement, and problem-solving
techniques to proactively address issues.
Parast and Golmohammadi (2019) discovered that the tools used in hospitals for
benchmarking are useful in assessing the organization’s quality system. Benchmarking,
among similar competitors, provides some indication of an organization’s performance
status. According to Cotrim, Filho, Leal, and Galdamez (2018), benchmarking compares
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planned and actual performance, projects, and practices to comparable performance and
projects to identify the best practices. When leaders can benchmark against their
competitors, they obtain invaluable information about whether they perform among the
best or identify opportunities for improvement. To institute an environment of continuous
improvement, leaders must use a performance measurement system to measure overall
management and performance (Thurer et al., 2018). Silombela et al. (2018) found that
leaders with a system that can trend data, identify problems, and trigger solutions can
effectively improve business operations. The company documents revealed a
comprehensive network of integrated business processes, aligned to strategic objectives,
and visual display boards of daily monitors to track performance.
Linkage to the HPWS conceptual framework. Posthuma et al. (2013) opined
that the design and use of the theory of high-performance work systems (HPWS) could
enhance how an organizations’ employees perform by improving engagement through
increasing capability, productivity, and commitment. Performance management is one of
several core practices found in the application of HPWS. Rasheed et al. (2017) stated that
highly competent employees pursue excellence and improve the organization as
managers empower and convey high expectations and outcomes of their employees. The
discovery of a robust system of performance measurement, analysis, and improvement
from the leaders interviewed at participating organization, supports the information found
in the literature and the conceptual framework used in this study as evidenced by all
interview participants' descriptions. The company documents detail how metrics that
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support various goals are cascaded, tracked, and available on visual display across the
campus. The leaders interviewed for this study explained the connection of performance
measurement to the strategic objectives and goals they establish across the organization,
revealing the next key theme: Strategy and Strategic Planning.
Theme 2: Strategy and Strategic Planning
A robust system reinforces the organizational strategy and engages all employees
(Kellner et al., 2017). According to Griffith and Patel (2017), models for organizational
excellence emphasize concentrating on strategic goals and the company's strategic
situation. The emphasis on strategy and strategic planning might explain why every
interview participant stated that many of their actions began with the organizational
strategic planning process. IP1 explained that during the strategic planning process, the
leaders developed goals that support the organization’s crucial pillars that align with the
strategic plan. Some of the pillars are quality, safety, workforce, patient satisfaction, and
medical staff. IP2 stated that the organization has multiple feedback loops to inform the
effectiveness of strategies in use. Annually, when starting the strategic planning process,
they examine data from all sources. IP3 discussed leadership's intentional alignment of its
strategic planning process with the finance and budget review cycle to ensure proper
resource allocation to support the goals. IP4 stated that the way leaders maintain the
“pulse” of the organization is through the use of scorecards with alignment to the
strategic goals. IP5 described their constant review of the scorecards after explaining the
process begins with strategic planning, setting goals and direction for the year, and
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cascading those plans to every individual in the organization. The organizational
schematic of the strategic planning process described each process step in intimate detail
and the roles involved in the planning, deployment, and performance improvement
phases of the plan. The leaders shared an example of the strategic plan that they prepare
annually. The annual plan includes the mission, vision, and cascading goals that align to
other crosscutting efforts such as employee engagement, employee turnover, patient
safety, and patient experiences. Silombela et al. (2018) stated that the management of
information, planning, and control of the system is paramount to achieve organizational
outputs. The organization’s comprehensive documentation of strategy and its strategic
planning process was outlined in several documents, visual displays, and articulated by
every interview participant. Table 2 is a summary of references to strategic planning.
Table 2
Reference to Strategy and Strategic Planning by Interview Participant
Interview
Participant
# of References Coverage
Words and phrases
IP1 2 10.99% strategic plan, strategy, pillars, planning, projects, goal deployment
IP5 1 18.47% systems and structures, reach our mission, strategic planning process, system-level scorecard,
IP3 0 14.26% strategic planning process, pillars, vision, strategies, integrate, interconnectedness
IP2 9 9.11% strategic planning process, strategic plan, roll-up of projects, pillars, alignment, planners
IP4 8 12.87% align strategically, strategic goals, cascading process, all levels of the organization
Every interview participant highlighted the necessity that business processes,
goals, projects, and initiatives all align with the strategic plan. Ferdowsian (2016) opined
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that leaders of organizations would not achieve excellent performance unless they satisfy
customers, engage, and align the workforce with the overall objectives and goals. IP3
described alignment with strategy as the place "where you make sure that everyone is on
the same page and singing from the same sheet of music." According to Posthuma et al.
(2013), organizational strategy within a high performing organization integrates strategy
and innovation at the policy level to provide guidance and direction while promoting a
creative work environment.
IP4 described the cascading process for strategic goals as a critical element to
drive engagement at the front lines. The level of engagement empowers employees as
they contribute to the overall goals and objectives of the organization, and it has become
a part of their culture. IP5 advocated for the robust strategic planning process and the
engagement of leadership at every level. IP5 stated that the top executives expect results
and hold everyone accountable for achieving successful outcomes. The organizational
procedure for the strategic planning process lays out the four phases of planning with
color-coding, process mapping, and a numbering sequence that is illustrative of the
sequential steps the leaders take to analyze, identify gaps, develop goals, cascade, report,
identify and track improvement, and review efforts continuously.
Linkage to the extant literature. Huang, Knittle, Wantuch, and Francis (2020)
discovered that healthcare administrators had changed their focus by integrating
technology into strategies to assist in the improvement of patient populations, engage
employees and patients, and phase in new efficiencies in operations. Strategic planning
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has a significant impact on an organizational focus on the customer and their satisfaction
(Parast & Golmohammadi, 2019). Singh and Sethi (2017) stated that the only way to
enhance organizational performance is by measuring what is essential, and the fulfillment
of this requirement. The participants from the partner organization, provided company
documents that describe the strategic planning process that identified vision, goals, and
areas of focus with an intricate planning process. The participants detailed an integrated
process for planning, deploying, and improving performance throughout the organization.
Lastly, the leaders use a balanced scorecard that lists high-level goals and special projects
reported quarterly with benchmarking against competitors.
Silombela et al. (2018) stated that leaders must establish various applications such
as problem identification, data analysis, process analysis, quality control, decision
making, and planning to be effective. Each interview participant explained an application
of each of these attributes in responses during their interviews. The span of leadership
control requires systematic oversight and data collection that informs culture, satisfaction,
portfolio performance, service delivery, strategy, and strategy execution through plans
(Saxena et al., 2018). All participants and company documents informed the existence of
a highly integrated, aligned, and widely known strategic planning process.
Thurer et al. (2018) stated the leaders must align inputs, outputs, and the customer
wants with the operations strategy to maintain strategic advantage. Alignment to meet
customer needs is paramount. Alignment of purpose, goals, and direction across an
organization is equally necessary to avoid mismatched or unmet customer or stakeholder
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needs. When targeting improvement to business processes in strategic goals, the tools
leaders use must also align with the comprehensive organizational strategy to ensure
transparent decision making supported by data (Laureani & Antony, 2017). All
participants discussed the alignment of strategic planning goals and objectives across
departments and the cascading effect on every individual in the healthcare system.
Linkage to the HPWS conceptual framework. Kellner et al. (2017) researched
the theory of high-performance work systems in organizations. They found the practice
of strategic management as an essential factor to survive while providing an optimal
balance of employee-focus to improve overall performance with leadership direction. In
response to the interview questions, the participants repeatedly emphasized the
importance of strategic planning to all of their organizational initiatives. According to
Parast and Golmohammadi (2019), leaders must engage the workforce in a way that
directs and creates a high-performing environment to enable employees to adapt to
change and succeed. The approach and expectations the healthcare leaders convey about
the strategic projects and employee engagement lead to the next key theme involving
leadership engagement. Ferdowsian (2016) stated that the best strategy for leaders
pursuing excellence is to establish a stable foundation in the fabric of the culture and with
a vision for high-performance and efficiency in day-to-day operations.
Theme 3: Leadership Direction, Sponsorship, and Engagement
Leadership is considered a vital attribute to improve quality and performance in
health care delivery (Saxena et al., 2018). Parast and Golmohammadi (2019) found that
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leadership and human resource practices are the two most important factors for quality
implementation in hospitals. Company documents outline leaderships' facilitation of
setting direction, establishing goals, cascading directives, monitoring action plans,
mentoring and development staff, and continuously improve business processes.
IP1 and IP2 explained the systematic review of projects and alignment to goals
and objectives with methods to monitor data throughout the performance period. IP1
strongly emphasized that the system design and areas of focus guide their organizational
performance. The customer requirements are the foundation and driver of every project to
ensure meeting patient needs. IP3 stated that the quality management system and
initiatives are the infrastructures that the leaders leverage as a governance board to track
and monitor all activities taking place across the organization. There are expectations that
leaders, at every level of the organization, cultivate an environment of creativity and
continuous improvement. All leaders are required to complete annual quality training to
include Six Sigma belt courses and certifications. The expectation is that leaders should
be competent in mentoring, coaching, and developing the workforce.
IP4 is a certified Six Sigma belt trained to lead and facilitate improvement
projects. They added that the training allowed them to inspire the workforce to adapt to a
culture of continuous performance improvement. IP5 explained that they also completed
specialized quality training and highlighted the importance of recognizing employees for
their engagement in improvement work as crucial for the realization of cost savings and
waste reduction each year. Laureani and Antony (2017) stated that quality training is a
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mechanism for engaging staff in improvement. Leadership must be visible, leading the
charge, and recognizing employees when they participate in projects that improve the
organization. All participants stated that organizational culture supports transparent
communication. collaboration, continuous improvement, and constant learning. The
organizational documents described the leadership system; a systematic approach to
deploying the mission, vision, strategic objectives, goals, and cascading of expectations
to employees. Another company document detailed the learning management system and
competencies for training the various roles across all departments. Table 3 provides a
summary of leadership direction, sponsorship, and engagement.
Table 3
Reference to Leadership Direction, Sponsorship, and Engagement by Interview Participant
Interview Participant
# of References
Coverage
Words and phrases
IP5 10 17.69% leadership, know the direction, drive the level of improvement, responsibility, focus, nursing leadership
IP4 9 20.73% review committee, leaders and executives, led the journey,
senior leader tenure
IP3 10 16.01% leadership triad, governance, leadership system, owner, senior- level, leadership model
IP2 7 15.22% improvement council, physician leadership, business
management
IP1 8 9.93% committee, leadership system, strategic & operational leaders, build commitment
Tickle et al. (2016) examined the business excellence practices and found that
organizations that possess approaches, systems, tools, and techniques are successful in
achieving an efficient operation. An approach includes resources such as strategic
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planning, project sponsorship, and management commitment in support of the mission
and work of a company. IP3 explained the quality management system in use by detailing
the committees and communicative methods that cascade throughout the organization.
The integrated system helps the leaders review projects and examine all activities that
occur to improve healthcare delivery. IP3 and IP4 stated that the leadership system they
have implemented aided the transformational organization to become a high-performing
system. IP5 described the leader’s role in strategic project execution and performance as
the champion with the responsibility to provide resources and remove barriers that
impede the staff from accomplishing goals. Roberts et al. (2019) found that leaders who
create an environment where employees learn to use improvement tools in regular
operations, with coaching, perform better than competitors. Leaders establish strategic
goals and continuously measure hospital quality performance because the data
contributes to the hospital's reputation compared to their peer organizations (Chakraborty
& Kaynak, 2018). IP4 opined that the cascading process from the strategic plan is the
critical element that drives employee engagement at the front lines. All participants and
organizational documents defined the expectation for leaders to facilitate and sponsor
improvement efforts throughout every department through a partnership with their
workforce.
Linkage to the extant literature. Leadership must inspire the need for an
organizational plan to improve performance, allocate resources, train the workforce in
improvement, and establish the structure to manage improvement initiatives (Henderson,
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O’Mara, Bishop, Arnold, & Whitfield, 2020). Laureani and Antony (2017) stated that
leaders who exhibit specific characteristics and traits are crucial in the deployment of
quality and continuous improvement programs. All of the interview participants detailed
their extensive involvement in business operations, continuous improvement, and the
strategic planning process on an ongoing basis. Communication, training, and employee
motivation were all critical factors in the experiences that each participant detailed in
their journey to achieve higher organizational performance. Strategies to increase the
adoption of improvement tools and a culture of continuous improvement are strong
leadership, upper management support, training, and strong alignment to strategy (Tickle
et al., 2015). Organizational documents clearly stated leadership expectations such as the
requirements that they understand vital goals, set direction, align and cascade goals to the
workforce, implement action plans, achieve plans, mentor and develop people, and adapt
systems and structures to support continuous performance improvement.
Linkage to the HPWS conceptual framework. Leaders who are successful in
achieving high-performance in healthcare create an environment where shared leadership
models with partnerships between the workforce, clinicians, and managers. Robbins et al.
(2012) found that leaders who implement the components of HPWS must demonstrate a
focus on performance and improvement. Leaders who foster an environment of
empowerment and sponsor projects that involve their staff positively influence the
workforce perception of the characteristics of a high-performing organization. All
interview participants discussed their roles as change agents and detailed how they
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communicated to the workforce about continuous improvement and learning beyond their
job duties. Organizational documents reference continuous learning, continuous process
improvement, and a focus on patients within an enterprise system model. Rasheed et al.
(2017) stated that leaders and subject matter experts must provide frequent
communication, interact with employees, give them a feeling of empowerment, and an
opportunity to participate in decision-making processes. The type of partnership and
engagement described in the literature and present in this organization leads to the next
theme, employee engagement.
Theme 4: Employee Engagement and Empowerment
Written reports, data metrics, and verbal dialogue among leaders and staff
promote constructive dialogue and engagement through story-telling about performance
and ongoing improvement (Brown, 2020). Saxena et al. (2018) discovered evidence
linking staff engagement in reducing patient complications and employee attrition.
According to Kellner et al. (2017), employee engagement is a vital tenet of the theory of
high-performing work systems (HPWS). The implementation of HPWS in healthcare
could have a positive impact and improve business performance. IP1 described employee
onboarding and training to include their introduction to the mission, vision, goals, and
pillars of the organization before they are required to complete various training modules
of quality and performance improvement. IP4 emphasized how leaders engage the
workforce through the introduction and alignment of the goals and the cascading process
impacting every individual’s performance plan.
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IP5 believes that employee recognition pathways engage employees by
showcasing efforts through the improvement of work. They celebrate their initiative
through recognition of in front of organizational leaders and peers. All participants in this
study reported the involvement of all employees, throughout the organization, in quality
training, process improvement projects, and innovation promoting techniques. The
organizational documents outlined leadership, middle-management, and employee
training and competencies, workforce expectations, use of organizational knowledge, and
evaluation measures. Company documents explained the knowledge, technology, and
information sharing policies, procedures, practices, and expectations for organizational
learning at every level of the workforce from senior leaders to employees across the
workforce. According to Roberts et al. (2019), to implement a quality-focused approach,
leaders must offer flexibility to engage employees, encourage their involvement in
decision making, and engage in actions focused on improvement. All participants shared
their many experiences engaging the workforce through various phases of evolution to
improve the work environment while cultivating a learning organization with a
determination to continuously improve the work, work processes, patient care, and the
overall patient experience.
Ferdowsian (2016) found that employees who were engaged would tirelessly
follow through with their work without an expectation for recognition, reward, or
financial incentives. When employees are committed to the organization, they are
motivated to perform and satisfy their customers because of their personal pride and
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positive outlook about their job. The leadership’s commitment to comprehensive basic
training in quality and improvement tools is essential to garnering engagement and
motivation to participate in project teams (Laureani & Antony, 2017). The definition of
business excellence includes the perception that an organization’s leaders prove that the
services provided are indispensable to customers and stakeholders, partner with their
suppliers, and exist in an inclusive employee environment. Metaxas et al. (2019) defined
business excellence as the satisfaction of stakeholders and customers while
simultaneously achieving an organization’s outstanding performance. Alternatively,
Tickle et al. (2015) stated that excellence in strategies, meeting stakeholder expectations,
and excellent business practices validated by assessments, define business excellence in
firms. The participants and partner organization provided company documents to support
stakeholder satisfaction rates, customer (patient) satisfaction rates, and business
performance outcome data to support their status in the top 10% of competitors for
similar community hospitals.
The organization was recognized for the Baldrige Performance Excellence
Program in healthcare after the leaders completed the application for an assessment and a
successful site visit by Baldrige Examiners. The interview participants describe their
employee engagement behaviors, including seeing the bigger picture, believing in the
mission, actively engaging to make the department better, and a positive perception of
their job and improvement projects. Throughout their “Baldrige journey,” which took
place over several years, the organizational leaders engaged the workforce by
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communicating plans to pursue organizational excellence, implementing specialty
training in quality and improvement methods, chartering several improvement projects,
and developing a regular reporting process to monitor performance metrics. Table 4 is the
frequency employee engagement was referenced.
Table 4
Reference to Employee Engagement by Interview Participants
Interview Participants
# of References Coverage Words and phrases
IP5 15 19.47% my team, their data, direct reports, everybody, everyone, employee unit-level orientation, we, engage employees, people, cadre, employee recognition
IP4 9 18.91% all members, across the organization, "all teach, all learn," driving employee engagement, members, development of the workforce, developing people
IP1 8 9.36% their goals, incentives, multiple staff categories, engage employees, everybody, every department, every individual, talent, coaching staff, folks, frontline staff
IP3 8 11.02% frontline level, down to every level, employees, employee engagement, feedback to staff, employees, longevity, loyalty, highly tenured staff, feed the culture, new folks
IP2 4 10.90% talent, folks, each level, people, each role, everybody's individual planner, workforce, information for employees
IP1 explained the cascading process of involving employees in projects that
support the strategic plan as both an incentive and a cultural expectation. Leaders expect
employees to participate in improvement projects within their assigned work area, and
successful participation positively impacts performance ratings and career development
opportunities. IP1 also described how mentoring and coaching for performance allows
leaders to identify talent within the workforce. It affords them a proactive opportunity to
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conduct succession planning as they identify potential talent during the progression of a
project. The organizational leaders have developed a robust program to grow their
workforce in specific areas of focus and offer specialty training options.
IP2 stated that emerging leaders, from the workforce, are often identified during
the annual performance review process to mentor and shape for future leadership
succession. Administrators will often work to establish development plans for interested
employees and individuals that express an interest in continuous learning and growth in
leadership and quality areas. All interview participants believed that any random
employee would be able to detail the strategic goals and improvement projects for their
department. The cascade of goals to all frontline employees, combined with a continuous
feedback loop, results in leaders and employees always discussing projects and problem
solving upon the discovery of opportunities.
According to IP3, employees stay involved with improvement efforts because
they complete annual quality training and receive coaching on projects within their
departments. The rewards and recognition pathways are two mechanisms that highlight
staff involvement in projects that also positively impact performance and staff
perceptions about the organization. The staff becomes a part of the solution when they
are empowered to innovate and try new ways of working and are recognized for their
accomplishments. IP3 stated that a critical factor of the continued success of an
organization is the longevity of the workforce and high tenure. The senior staff feeds the
positive culture and orient the new employees when they start working who observe their
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co-worker connectedness to the mission, sharing of knowledge, and experiences.
IP4 stated that the cascade process for projects to frontline staff contributes to the
organization's success because the employees often develop ideas for the department
projects that align with the strategic plan. Lasrado et al. (2017) found that organizations
are successful with innovation at work when employee ideas thrive, and they observe the
implementation of their suggestions into new programs. Employees are motivated and
empowered when asked to provide suggestions or recommendations to improve
operations. IP5 described the evolution of staff engagement and recalled the power of
involving frontline staff to improve healthcare as the transformational milestone for the
organization. The organizational leaders developed an innovative system to harness
employee ideas to ensure proper resourcing and vetting for successful implementation.
Linkage to the extant literature. The research findings highlight a linkage
between leadership, engagement, and the improvement of healthcare outcomes (Brown,
2020). Stoyanova and Iliev (2017) emphasized that employee engagement, expressed in
mental, emotional, and physical connection with the company, must inspire them and
make them feel that they contribute to the organization’s development and success. The
sustained success of the partner organization, involved in this study, is believed in part
due to the involvement of every employee within the healthcare delivery system. Bakker
(2017) suggested that the key to attracting and maintaining a high-performing, engaged,
and productive workforce is by providing work context that is an excellent fit with the
employees’ expectations for their role and the work environment. Laureani and Antony
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(2017) stated that the transformational leadership style is essential to inspire employees
when communicating the need for change, garnering commitment to the mission and
vision of the organization and cultivating an environment of continuous learning and
improvement.
Linkage to the HPWS conceptual framework. Lee et al. (2016) suggested that
the use of HPWS has the potential to enhance organizational performance through actions
that improve employee commitment, productivity, capability, and leveraging their
expertise as the primary source of competitiveness. IP5 described how nursing cadre
engages in improvement projects and problem-solving discussions when data for tracking
goals reveal opportunities for improvement. IP5 stated by involving the nurse managers
in the problem-solving conversation, their level of commitment and, using their expertise
solidified sustainable actions with minimal changes. Organizations that maximize the
engagement of employees increases the workforce empowerment, commitment, tenure,
and responsibility for the outcomes, goals, and key initiatives. According to Etchegaray
and Thomas (2015), the employee engagement component of HPWS was prevalent in
50% of companies under study. The organizational documents discuss employee and
workforce engagement as a partnership with leadership and management to achieve
goals, objectives, and projects that align with the strategic plan. Saxena et al. (2018)
opined that the engagement of staff is vital for improving patient outcomes, reducing
patient complications. The joint-partnership paradigm drives the overall performance to
manage costs and achieve operational efficiency. They are engaging the workforce while
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managing resources that support their efforts segue to the last major theme.
Theme 5: Resource Management
All interview participants emphasized the importance of properly managing
resources to achieve goals and significant objectives. IP1 explained that department-level
projects include factors that address budget reduction, waste management, or cost-saving
projections. When data indicated the lack of fully expensed departmental budget
allocations, organizational leaders discovered the additional benefit of improvement
initiatives due to staff saving resources during projects. IP2 described direct involvement
of the chief financial officer and chief informatics officer on the quality improvement
council to advise about the impact of resources during project discussions. The use of
lean and other process improvement methods not only improve the quality and timeliness
of service but can also lower expenses in organizations (Laureani & Antony, 2017). IP3
discussed the widespread use of Lean and Six Sigma, by improvement teams, chartered
from a continuous loop of project identification aimed at improving the patient
experience. The managers examine the impact of the projects concerning the cost of care,
length of stay, and revenue generation as balancing measures to help with decisions about
initiatives and the potential to improve quality outcomes.
IP4 outlined the leadership review method to ensure any project they use with
time, energy, or monetary investment in full alignment with the priorities of the strategic
plan. IP4 stated that any organization could obtain tools and techniques aimed at
maximizing products or services, however, to attain a high level of performance, leaders
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must drive the culture of improvement and create the optimal environment to utilize the
tools accurately while teaching staff along the way. Chakraborty and Kaynak (2018)
stated that healthcare performance includes the tracking of quality of care, cost,
utilization, patient satisfaction, finances, and hospital resource efficiency for maximum
use. Training and tracking are paramount to any resource utilization schema. IP5
emphasized employee participation in quality training in Lean, Six Sigma, 5S, and
process mapping to help the organization become conscientious about resources and
examining initiatives that add value.
All of the interview participants believed the environment of collaboration and
communication allows leaders and staff to make equal contributions, thereby collectively
managing resources while continually finding ways to perform work more efficiently and
effectively. All the participants stated that tools and their systematic approach enabled
controlling operational costs, waste reduction, and cost savings. The deployment and use
of Six Sigma were beneficial to standardize work processes, reduce variation by
constantly identifying and eliminating waste, increase automation, and enhance
workforce productivity through innovation. The organization’s quality procedures
indicated the tracking of cycle time within the workflow, productivity across departments
for similar work tasks, and other in-process measures reported through various
scorecards. Saxena et al. (2018) found that shared responsibility for resources,
integration, and efficiency in operations lead to success. Table 5 includes the frequency
resource management was referenced by IPs.
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Table 5
Reference to Resource Management by Interview Participants
Interview Participant
# of References
Coverage
Words and phrases
IP5 7 10.88% planning, projects, save costs, reduce waste, stewardship, able to maximize, contributing to overall margin, reminding people, sharing the same message
IP4 6 15.55% key facets, resource-time & energy, cost-saving initiatives, focus, financially viable, cost metrics, eliminate unnecessary cost
IP1 6 6.81% budget, manage waste, cost reductions, inflation is our enemy, we experience increases in costs and benefits, cut their expenses, cut expenses
IP3 8 12.26% Identification of projects, aligned strategy with budget planning, cost driver, intentional about projects, balancing measures, good stewards
IP2 7 11.27% project alignment with initiatives, cost/quality/access approach, added costs, balance, not all about the $
Linkage to the extant literature. Madlabana, Mashamba-Thompson, and
Petersen (2020) highlighted the need for healthcare employees to be competent, feel
rewarded for their contributions, and equipped with the necessary tools to ensure
excellent performance. According to Matthew (2014), firms with excellent resource
management practices such as actions to socialize, train, motivate, evaluate, and
compensate employees achieve not only organizational goals but also produce high-
performing individuals. All interview participants described similar characteristics about
their workforce during the research interviews. A highly tenured staff maintains
institutional knowledge and efficiently manages resources, which ultimately results in
cost savings. Hong, Jiang, Liao, and Sturman (2017) asserted that the management of
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resources is an organization's most valuable asset for long-term success, sustainability,
and survival. IP1 detailed the daily auditing practice across departments through the
visual displays that outline the goals and objectives that align with organizational
strategy. IP2 stated that the daily controls, various internal and external feedback loops
provide insight for leaders and managers to monitor and adjust resources as needed. IP3
believed the integration of various systems and daily monitors ensure staff is not just
performing a bunch of random activities that do not advance or support the strategic
goals. IP4 highlighted the use of tools and monitors to track the goals to focus everyone
and engender a culture of continuous improvement and efficiency of operations. IP5
recalled the pride the nursing workforce feels when contributing to improvement
initiatives that have a major impact on organizational resources, save costs, reduce waste,
and improve patient care.
Linkage to the HPWS conceptual framework. Resource management practices
such as employee development, selective hiring, pay-for-performance, and employee
incentives are commonly used HPWS practices in healthcare. The leaders from the
partner organization provided several examples that demonstrate the use of these
practices in their health care system. Shin and Konrad (2017) stated that organizations
adopt the various tenets of HPWS and other non-related strategies iteratively. Leaders
and staff accumulate knowledge and experience that leads to a high-performing company.
The company documents describe the organizational system of learning that includes
drivers for culture, innovation, and measurements. The interview participants detailed the
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organization’s robust process for employee development at the senior leaders, middle
management, and workforce levels. IP3 and IP5 highlighted the low turnover rates,
retention, and tenure of the workforce and how the continuity contributes to their success
and high performance.
Other Contributing Strategies
Interviewing these five healthcare executives to explore the strategies that
successfully helped them achieve excellent performance within their organization was
most revealing. The common themes from each participant were performance
measurement and analysis for improvement; strategic planning; leadership direction,
sponsorship, and engagement; employee engagement and empowerment; and resource
management. In addition to similar thematic input from the interview participants, there
were other strategies they shared using other frameworks in tandem during their
organizational excellence journey. Some of these strategies included using a quality
consultant and developing a quality management program equipped with training, tools,
and techniques.
Leaders often use several methodologies or frameworks in tandem when
attempting to positively shift organizational performance or service delivery. Chakraborty
and Kaynak (2018) stated that tenets from several methods or approaches could be
complementary, offering an overarching roadmap that incorporates strategies from
various frameworks with a focus on healthcare quality. The executives employed with the
partner organization participating in this study highlighted their use of Baldrige, change
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management principles, Magnet status for nursing, and Six Sigma methodologies. The
executives contracted a consultant, with expertise in all the methods and frameworks in
use, to provide coaching and advise the leadership council in their planning.
The use of a consultant with extensive experience with Baldrige, improvement,
and customer focus was essential to the excellence journey described by the executives
interviewed during this study. Griffith and Patel (2017) advocated for a cadre of
consultants with a deep understanding of quality to assist with implementation plans.
There are several consulting firms that aid with business process improvement, change
management, understanding Baldrige, patient safety, and strategic planning. The use of a
consultant can be helpful working alongside leaders to develop and plan the changes and
improvement in an organization.
According to Ferdowsian (2016), organizations that enhance their internal training
programs with engaged leadership proactively prevent costly issues during their journey
to excellence. Each participant in this study discussed requirements for training the
workforce as a subset of the leadership strategy to engage the workforce. The partner
organization involved in this study employs an in-house quality cadre to facilitate training
and improvement projects and a consultant to advise the leadership of their overarching
long-term strategies. The executives and the partner organization that participated in this
study demonstrated effective use of QM tools and techniques to achieve organizational
excellence in healthcare and have sustained their status for the past ten years.
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Applications to Professional Practice
U.S. public hospitals have less resources for quality health care delivery,
compared to private and for-profit hospitals, and must control finances and quality of care
despite the challenges of caring for the uninsured and underinsured patient populace (Po,
Rundall, Shortell, & Blodgett, 2019). This study provides insight into the strategies used
by healthcare executives to employ quality approaches to attain operational efficiency,
reduce expenditures, and ultimately achieve organizational performance excellence. The
strategies that each interview participant shared have been proven to be successful and
had a positive impact on improving their operations. The application of a performance
measurement system to identify opportunities for improvement, a robust strategic
planning process, engagement of leaders and all employees, and the deliberate
management of resources will reduce healthcare expenditures, waste of supplies and
equipment, improve operational efficiency, and improve both patient care and their
satisfaction.
Healthcare leaders need strategies that they can implement, sustain, and result in
timely improvements that will result in a positive impact on operations. Performance
reporting and analysis enables organizations to identify areas for improvement, track and
support change efforts, and provide information about outcomes (Levesque & Sutherland,
2020). The best leaders gather information, plan, engage with others, and take action to
drive results (Pater, 2020). The key to an engaged workforce includes retention strategies,
job satisfaction efforts, training, onboarding, and acculturation into an organization
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(Shufutinksy & Cox, 2019). Polonsky (2019) stated that leaders must acknowledge
failures and embrace vulnerability on their journey to engage with their workforce to
identify opportunities for improvement, create the need for change, and cultivate an
environment committed to providing the best possible care.
Quality improvement in healthcare has been the focus of research studies for more
than 20 years without the discovery of one solution that works for every organization
(Chakraborty & Kaynak, 2018). A combination of methods and approaches that leaders
learn, master, and leverage to act based on the needs of the organization. An awareness of
the successful strategies that healthcare executives use to achieve an optimal level of
performance, effectiveness, and efficiency can be applied by leaders in other healthcare
delivery systems and beyond.
Implications for Social Change
Hospitals that provide the best possible care for patients prolong the life of
individuals and lead to healthier communities. Thurer et al. (2018) found that
organizations that sustain excellence have little to zero waste, positive patient
satisfaction, and consistently higher scores for clinical patient outcomes. Learning the
strategies from leaders who have successfully achieved and sustained operational
excellence can be used as a model to implement similar practices in other healthcare
systems. Using quality cadre and consultants with expertise in quality tools and
techniques equips organizational leaders to strategically develop plans to gradually make
iterative changes to improve business proficiency and healthcare delivery. The use of
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qualified consultants with specialized experience allows the organization to improve
patient care more effectively and steadily to achieve an efficient operation (Adams et al.,
2015).
Recommendations for Action
Healthcare executives and their senior leadership team can utilize the strategies to
implement similar efforts on a journey toward excellence or operational efficiency. The
strategies provided may align business processes, engage leaders and employees in other
ways, refocus on patient needs, save costs, reduce waste, and train the workforce on
methods for continuous improvement. Sharing the results of this study and information
via presentations through the annual conferences or training courses could raise
awareness. The most useful conferences include those hosted by national organizations
for quality such as the American Society for Quality, the National Institute for Standards
and Technology, academic institutions, or other quality-focused webinars. The
dissemination of results can include articles published in peer-reviewed journals. The
specific recommendations that may assist other health care organizations to include: (a)
make a decision to pursue business process improvement and seek better operational
efficiency; (b) implement the strategies deployed in high-performing organizations such
as training and sustaining a highly trained and qualified workforce, employee and leader
engagement, knowledge management initiatives, performance-based pay, and
empowerment through job design; (c) invest in training for leadership, and the entire
workforce, in quality approaches, tools, and techniques useful in process improvement
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such as Lean, Six Sigma, 5S, performance measurement, PDCA, customer surveys, and
create a robust quality management system; (d) charter councils or committees that have
overarching oversight of the processes that span the organization with a focus on the
management of the process, metrics, knowledge, resources, projects, and initiatives
focused on the voice of the customer (patient), and comparatively benchmark clinical
outcomes with similar hospitals; (e) create and hire a quality management consultant or
team for in-house expertise to build a QM program; and lastly (f) assess the
organization's success with their journey to excellence by applying to award winning
programs such as Baldrige, EFQM, the Deming Prize, or other quality and business
assessments.
Recommendations for Further Research
The purpose of this qualitative single case study was to explore strategies that
hospital leaders use to effectively employ quality management approaches to improve
processes and achieve organizational performance excellence. After completing
interviews with healthcare executives and conducting data analysis, I identified five
themes that are critical for leaders to leverage quality management methods to achieve
organizational excellence in healthcare: (a) measurement and analysis for improvement
(b) strategy and strategic planning, (c) leadership direction, sponsorship, and engagement,
(d) employee engagement and empowerment, and (e) resource management.
This study had three limitations: sample size, transferability of results to other
industries than healthcare, and my ability to manage personal bias regarding the use of
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QM tools and techniques. Future researchers should consider larger sample sizes, such as
multiple case studies, to explore leadership strategies in pursuit of excellence. Future
research efforts could explore the same business problem in a different industry other
than healthcare. Lastly, to manage personal bias, future researchers should develop an
interview protocol to ask standard questions of every interview participant and report the
data collected during the study regardless of conflicting or contradictory evidence. Given
these limitations and my discoveries during the research process, I recommend the
following considerations for further research: a) further, explore the utilization of the
strategies when implemented in other healthcare organizations with different
complexities of patient care, b) conduct a quantitative or mixed-methods study to explore
the various strategies and current utilization in healthcare organizations with excellent
performance, high patient satisfaction, and high operational efficiency, c) explore the
utilization of the strategies when implemented in other industries, d) research the role and
impact of the quality practitioner and cadre in an organization, and e) research the
utilization of models and theories of organizational excellence.
The Role of the Quality Practitioner in an Organization
Yankelevitch (2015) opined that the function of the quality department in an
organization is limited, resulting in nominal involvement and contribution to achieving
company results. The role of the quality practitioner should evolve with deliberate
planning at the executive level within a company. The quality department is a
foundational function that boundary spans the organization with constant engagement
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with staff in operations, logistics, communications, marketing, finance, and core business
practices (Yankelevitch, 2015). Leaders need staff with experience and expertise with
quality tools, change management methods, and strategic planning techniques to stay
abreast of constant changes in every business industry. Augmenting the use of quality
management methods with other frameworks might enhance an organization’s pursuit of
excellence.
Knowledge About Organizational Excellence Models and Frameworks
As businesses, across all industries, search for approaches to improve operational
efficiency and increase competitive advantage. New theories and models of excellence
have emerged that leaders could leverage for use and implementation of practices. Dawn
Ringrose (2013) examined existing organizational excellence frameworks available
internationally and in every industry to elucidate and consolidate the practices and
principles of existing frameworks to fill the void of an implementation guide. Several
flagship organizations, with excellent performance, are sharing their business excellence
models for application and implementation in other companies. Thurer et al. (2018)
identified three prominent business excellence models: Tom Peters’ model, G. Kanji’s
model business excellence, and the 4P Model by Dahlgaard-Park and Dahlgaard. There
are over twenty different operational excellence definitions that are further delineated
based on service, operational, and business excellence descriptions. Metaxas and
Koulouriotis (2019) take great care and consideration to carefully examine the various
journals and context that exists in current literature regarding business excellence models
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(BEM). Additional research to further explore BEM frameworks across sectors is an area
ripe for future ventures.
Organizational excellence framework. Ringrose (2013) conducted extensive
research on the leading practices across several management frameworks across the
globe. The result of the research includes a global framework for organizational
excellence independent of an assessment process or an award program. The
organization's excellence framework (OEF) includes nine principles, nine key
management practices, managerial areas of focus, and organizational areas of focus.
Metaxas and Koulouriotis (2019) defined organizational excellence as the simultaneous
state of satisfaction among stakeholders and customers based on the measured
performance of a company’s critical success factors. Additional research is needed to
explore the development and testing of excellence frameworks for use in all industries
(Metaxas & Koulouriotis, 2019; Ringrose, 2013).
Operational Excellence (Op-Ex). Found et al. (2018) described a business model
used in Boston Scientific as a whole system approach for achieving strategic, operational
excellence. Further study of this model reveals underpinnings or linkages to concepts
such as Lean, agile, and the Toyota production system. The Institute for Operational
Excellence (Powell & Strandhagen, 2012) opined that organizations achieve operational
excellence when each employee in a company can articulate the flow of value and
problem-solve to proactively and continuously identify problems before breakdown.
Although the Op-Ex model does not currently include a unifying theory, the compilation
110
of existing theories and dimensions can be useful by leaders in other industries and
sectors (Found et al., 2018). Future qualitative or quantitative research to further explore
this model for use in other industries may lead to widespread use or an update or
unification of more than one QM methodology.
111
Reflections
The doctoral journey has afforded me a greater appreciation of the research
process and challenged my abilities to write with an academic voice. Before beginning
my doctoral journey, I worked for years in the military and the federal government: these
environments required an entirely different style of writing, gathering and reporting data,
and preparation of correspondence. I currently work in the area of quality management,
and my working environment experiences are quite different from the strategies
discovered in the academic and professional literature and the partner organizations’
findings. For me to successfully navigate the doctoral process, I had to unlearn various
habits in writing, learning, data collection, accepting feedback, and interacting with peers.
I am immensely grateful for the experience and possess greater humility and openness for
feedback and facilitation of ideas. I am now equipped with the knowledge and procedural
approach to research and to make scholarly contributions to healthcare and quality
professions. I believe I can research with confidence to produce results with the highest
rigor and ethical integrity learned from the doctoral process. After I complete this study, I
will continue to identify topical areas of research and utilize the skills acquired from my
academic experience to make contributions to advance the field of quality and quality
management.
Conclusion
The purpose of this qualitative single case study was to explore strategies that
hospital leaders use to employ quality management approaches effectively to improve
112
processes and achieve organizational excellence. I conducted this research study with
healthcare executives in a partner organization that has successfully leveraged quality
tools and techniques to pursue improved operational efficiency. The findings from this
study may contribute to social change by improving healthcare delivery, resulting in a
healthier patient population and community.
113
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Appendix A: Interview Protocol
What You Will Do What You Will Say: Script
Introduce yourself,
summarize the purpose for the
interview and provide an
overview of the process.
Hello. My name is Cherron Blakely and I am a
doctoral student in the Doctor of Business
Administration (DBA) program at Walden University.
Thank you for taking the time to participate in this
study called “Leadership Strategies to Achieve
Organizational Excellence.” This interview will be
recorded and any information I collect will remain
confidential.
Process steps:
• Ask participant research
and interview questions’
• Watch for nonverbal cues
and body language;
• Ask follow-up probing
questions to get more in-
depth responses.
Research Question
What strategies do leaders use in community
hospitals to effectively employ quality management
resources to improve operations and achieve
organizational excellence?
Interview Questions
1. How does your organization define
organizational performance excellence?
2. What quality management approaches do you
use within your organization for achieving
operational efficiency and improvement?
3. How do you assess the effectiveness of your
strategies to achieve the desired performance
outcomes?
4. How does your organization identify and
prioritize the initial projects for justifying and
142
demonstrating the benefits from improving
operations?
5. What types of overall quality management or
improvement training does your organization
provide to leaders, managers, and employees
who participate in improvement strategies?
6. What strategy is used to obtain employee
involvement in improvement efforts?
7. How does your organization use cost or
performance metrics to prioritize improvements
in your organization's key business processes?
8. What additional information would you like to
share about your organization's leadership
strategies to effectively employ quality
management approaches to improve processes
and achieve organizational performance
excellence?
Wrap up interview;
thank participant.
This concludes the interview. I would like to
thank you for your participation in this study.
Explain to the
participant the process for their
review of an interview
summary. Provide a timeframe
when the participant will
receive follow-up email for
their review of the summary.
I will playback the recording of the interview we
have completed today. Within a week, I will provide
you with a summary of your responses for each
question. I will ask that you confirm, by responding to
my e-mail, that the information is accurate. You will be
able to confirm if I have missed any information or to
add any additional information.
143
Follow-up Member Checking
Send an e-mail to each
individual participant with a
summary of their responses.
(Email message content): I have reviewed the
recording of your interview; a summary of your
answers from the recorded interview is included in this
message. Please confirm by e-mail if this information is
correct for the following questions. Please let me know
if I have missed anything and if there is anything you
would like me to add.
1. Question, summarized response and synthesis of
the interview interpretation as needed.
2. Question, summarized response and synthesis of
the interview interpretation as needed.
3. Question, summarized response and synthesis of
the interview interpretation as needed.
4. Question, summarized response and synthesis of
the interview interpretation as needed.
5. Question, summarized response and synthesis of
the interview interpretation as needed.
6. Question, summarized response and synthesis of
the interview interpretation as needed.
7. Question, summarized response and synthesis of
the interview interpretation as needed.
8. Question, summarized response and synthesis of
the interview interpretation as needed.
9. Question, summarized response and synthesis of
the interview interpretation as needed.
144
Appendix B: Interview Questions
1. How does your organization define organizational performance excellence?
2. What quality management approaches do you use within your organization for
achieving operational efficiency and improvement?
3. How do you assess the effectiveness of your strategies to achieve the desired
performance outcomes?
4. How does your organization identify and prioritize the initial projects for
justifying and demonstrating the benefits from improving operations?
5. What types of overall quality management or improvement training does your
organization provide to leaders, managers, and employees who participate in
improvement strategies?
6. What strategy is used to obtain employee involvement in improvement efforts?
7. How does your organization use cost or performance metrics to prioritize
improvements in your organization's key business processes?
8. What additional information would you like to share about your organization's
leadership strategies to effectively employ quality management approaches to
improve processes and achieve organizational performance excellence?